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Cavernous Sinus Thrombosis Medication

  • Author: Rahul Sharma, MD, MBA, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: May 10, 2016
 

Medication Summary

Antibiotic therapy ideally is started after appropriate cultures but should not be delayed if difficulties exist in obtaining specimens. Antibiotics selected should be broad-spectrum, particularly active against S aureus, and capable of achieving high levels in the cerebrospinal fluid. With the recent increased prevalence of community-acquired MRSA, the emergency physician should consider additional coverage with intravenous antibiotics, such as vancomycin, if MRSA infection is suspected.

However, a case report and literature review by Naesens et al of community-acquired MRSA infections of the central nervous system, including cavernous sinus thrombosis, showed that patients treated with linezolid had a better outcome than those treated with vancomycin.[11]

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Antibiotic, Miscellaneous

Class Summary

Empiric broad-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms is necessary. Therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

In cases of suspected MRSA infection, vancomycin should be added for additional coverage.

Oxacillin (Bactocill)

 

A bactericidal antibiotic that inhibits cell wall synthesis. Used in treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when staphylococcal infection is suspected.

Ceftriaxone (Rocephin)

 

Alternate antimicrobial choice. Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms than earlier generation cephalosporins. By binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.

Metronidazole (Flagyl)

 

Additional anaerobic coverage. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually employed in combination with other antimicrobial agents (except when used for Clostridium difficile enterocolitis, in which monotherapy appropriate).

Chloramphenicol (Chloromycetin)

 

Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.

Vancomycin

 

Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.

To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.

Used in conjunction with gentamicin for prophylaxis in penicillin allergic patients undergoing gastrointestinal or genitourinary procedures.

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Anticoagulants

Class Summary

Unfractionated IV heparin and fractionated low-molecular-weight SC heparins are the 2 options in anticoagulation therapy.

Heparin

 

Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse thrombus but able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis. Various dosing nomograms available.

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Corticosteroids

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli. When the course of CST leads to pituitary insufficiency, corticosteroids definitely are indicated to prevent adrenal crisis.

Hydrocortisone (Solu-Cortef, Westcort)

 

DOC due to its mineralocorticoid activity and glucocorticoid effects. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Useful in management of inflammation caused by an immune response.

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Contributor Information and Disclosures
Author

Rahul Sharma, MD, MBA, FACEP Medical Director and Associate Chief of Service, NYU Langone Medical Center, Tisch Hospital Emergency Department; Assistant Professor of Emergency Medicine, New York University School of Medicine

Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Association for Physician Leadership, Phi Beta Kappa, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Edward Bessman, MD, MBA Chairman and Clinical Director, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

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Anatomy of cross section of cavernous sinus showing close proximity to cranial nerves and sphenoid sinus.
 
 
 
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