Medication Summary
Antibiotic treatment should be initiated as soon as the diagnosis is reasonably considered, and is most often used in conjunction with abscess aspiration or surgical therapy. The usual duration of antibiotic therapy is 3-4 weeks, but may be lengthened in the presence of osteomyelitis.
As mentioned, in select stable patients, antibiotic therapy may be briefly delayed until material is obtained for culture.
Antibiotics
Class Summary
Because S aureus is a common pathogen, anti-staphylococcal drugs should be included in the treatment regimen. An anti-staphylococcal penicillin, a cephalosporin, or vancomycin may be used. Again, with the increasing incidence of methicillin-resistant staphylococcal infections, coverage that includes an antibiotic that is effective against MRSA is recommended, which can be narrowed once cultures and sensitivities have resulted. If the patient has undergone a neurosurgical procedure recently, the penicillin should be combined with a third-generation cephalosporin and an aminoglycoside. Gram-stain and culture results are used to guide therapy.
Ceftriaxone
Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
Nafcillin
Treats infections caused by penicillinase-producing staphylococci. Used to initiate therapy in any patient in whom penicillin G-resistant staphylococcal infection suspected. Should not be used for treatment of penicillin G-susceptible staphylococci.
Parenteral therapy used initially in severe infections. Very severe infections may require very high doses. As condition improves, parenteral therapy should be changed to oral therapy.
Because of occasional occurrence of thrombophlebitis associated with parenteral route, particularly in the elderly, parenteral route should be used only for short term (24-48 h) and changed to oral route, if clinically possible.
Cefazolin
First-generation semisynthetic cephalosporin, which by binding to penicillin-binding proteins arrests bacterial cell wall synthesis and inhibits bacterial growth. Active primarily against skin flora, including S aureus. Total daily dosage is same for both IV and IM routes.
Metronidazole (Flagyl)
Used in combination with other antibiotics in epidural abscess following neurosurgical procedures. Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells, and intermediate-metabolized compounds formed bind DNA and inhibit protein synthesis, causing cell death.
Gentamicin
Used in combination with other antibiotics for epidural abscess following neurosurgical procedures. Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution. May be administered IV or IM.
Vancomycin
Often used when MRSA or other resistant organisms are suspected. Potent antibiotic directed against gram-positive organisms and active against enterococci species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or whose conditions have failed to respond to penicillins and cephalosporins, or those who 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 with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.
-
Cervical epidural abscess with spinal cord compression and spinal cord edema.
-
Spinal epidural abscess lumbar area.
-
An MRI of the lumbar spine (T1-weighted, post-contrast) shows a spinal epidural abscess at the level of L3-L4, with an associated left paraspinal muscle abscess.
