eMedicine Specialties > Emergency Medicine > Neurology
Spinal Cord Infections: Treatment & Medication
Updated: Sep 14, 2009
- Overview
- Differential Diagnoses & Workup
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Treatment
Prehospital Care
- Because the course of this condition is measured in days and not in hours (some patients take several months to present to medical care), patients' arrival by Emergency Medical Services (EMS) transport is unlikely.
- If presented with a patient who requires EMS transport, oxygen, analgesia, and a position of comfort are the only treatments needed in the prehospital arena.
- In patients in whom meningismus is involved, antiemetics and gentle handling are indicated.
Emergency Department Care
- Because this is such a rare entity, making the diagnosis in the ED is likely difficult. The emergency physician should consider the diagnosis when an infectious picture is present along with neurologic deficits originating at the spinal cord level.
- Treatment goals include making an accurate diagnosis and starting antibiotics as early as possible.4
- Determining the extent of the motor and sensory deficit and its levels is important to guide diagnostic modalities later. Examine the cervical, dorsal, and lumbar regions carefully looking for dermal sinuses, suggestive lesions, and signs of local infection.
- Plain radiography of the involved spinal levels occasionally can offer a clue when abnormal.
- A lumbar puncture always is considered in a patient with a septic picture with neurologic involvement; however, remember that besides cell count, protein, glucose, and bacteriologic studies, manometric maneuvers can establish the diagnosis of CSF block. Again, neuroimaging (especially MRI) of the spine has made CSF manometry largely obsolete for detecting spinal canal block. If a dermal sinus is found in the lumbar region, deferring the lumbar puncture until the absence of a tethered cord syndrome can be ascertained is prudent.
- Start antibiotics as soon as the bacteriologic workup samples have been obtained. Concomitant risk factors determine the most optimal antibiotic coverage for each individual patient.
- The use of steroids to treat spinal cord swelling should be made in consultation with neurosurgery.
- For additional information, see Spinal Cord Abscess and Spinal Cord Tumors - Management of Intradural Intramedullary Neoplasms.
Consultations
- The neurosurgeon should be involved early to guide the diagnostic flow toward surgery.
- An infectious disease consultant can offer invaluable help regarding the best antimicrobial combination.
- Consult a neuroradiologist to read the MRI with gadolinium study.
Medication
The goal of therapy is to eradicate infections. The empiric antimicrobial therapy should take into account the mechanism of infection, which helps predict the most likely infection organism or organisms.
For example, for contiguous spread through a sinus tract opening, one suggested regimen is vancomycin plus cefotaxime plus metronidazole.
For postneurosurgical complication, a suggested regimen consists of vancomycin plus ceftazidime with or without metronidazole.
For cryptogenic infection (ie, no identified primary source), a suggested regimen is ampicillin plus cefotaxime plus metronidazole. Ampicillin must be administered to cover L monocytogenes.
For hematogenous spread, the choice of antibiotics obviously depends on the primary source of infection. The optimal duration of antimicrobial therapy is not well defined. One review recommended a minimum of 4-6 weeks of parenteral therapy, with consideration of an additional 2-3 months of oral antimicrobial therapy.
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Vancomycin (Vancocin, Vancoled, Lyphocin)
Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or who have infections with resistant staphylococci.
Adult
500 mg to 2 g/d IV divided tid/qid for 7-10 d
Pediatric
40 mg/kg/d IV divided tid/qid for 7-10 d
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure and neutropenia; "red man" syndrome is caused by too-rapid IV infusion (dose given over a few min) but rarely happens when dose administered IV over 2-h administration or as PO or IP administration; "red man" syndrome is not an allergic reaction
Cefotaxime (Claforan)
Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.
Adult
Moderate-to-severe infections: 1-2 g IV/IM q6-8h
Life-threatening infections: 1-2 g IV/IM q4h
Pediatric
Infants and children: 50-180 mg/kg/d IV/IM divided q4-6h
>12 years: Administer as in adults
Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; has been associated with severe colitis
Metronidazole (Flagyl IV, Metro IV)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).
Adult
Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h
Maintenance dose: 6 h following loading dose; infuse 7.5 mg/kg or 500 mg IV over 1 h for 70-kg adult q6-8h; not to exceed 4 g/d
Pediatric
Administer as in adults using body weight
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiramlike reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Ceftazidime (Ceptaz, Fortaz, Tazicef, Tazidime)
Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
250-500 mg to 2 g IV/IM q8-12h
Pediatric
Neonates: 30 mg/kg IV q12h
Infants and children: 30-50 mg/kg/dose IV q8h; not to exceed 6 g/d
Adolescents: Administer as in adults
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Ampicillin (Marcillin, Omnipen, Principen, Polycillin-N)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Adult
250-500 mg PO q6h
500 mg to 3 g IV q4-6h; not to exceed 12 g/d
500 mg to 1.5 g IM q4-6h
Pediatric
50-100 mg/kg/d PO divided q4-6h
100-400 mg/kg/d IV/IM divided q4-6h
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
More on Spinal Cord Infections |
| Overview: Spinal Cord Infections |
| Differential Diagnoses & Workup: Spinal Cord Infections |
 Treatment & Medication: Spinal Cord Infections |
| Follow-up: Spinal Cord Infections |
| Multimedia: Spinal Cord Infections |
| References |
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References
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Further Reading
Keywords
spinal cord injury, SCI, anterior cord syndrome, Brown-Séquard syndrome, central cord syndrome, conus medullaris syndrome, cauda equina syndrome, incomplete SCI syndromes, spinal cord concussion, spinal cord injury syndromes, SCIWORA, spinal cord injury without radiologic abnormality
injuries of the spinal cord, neurogenic shock, spinal shock, spinal fractures, spinal dislocations, spinal epiduralhematomas, spinal epidural abscesses, spinal cord compression, complete cord syndromes, incomplete cord syndromes, hemorrhagic shock
