Epidural Abscess Medication

Updated: Nov 11, 2022
  • Author: Mark R Wallace, MD, FACP, FIDSA; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...

Medication Summary

The duration of antibiotic therapy is not well defined, but 4-12 weeks is generally considered adequate. Concomitant osteomyelitis requires a 6- to 12-week course. A transition to highly bioavailable oral agents might be appropriate in some cases; rely on an infectious disease specialist consultant for guidance. (See Medical Treatment for empiric selections.) Monitoring the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) value may be helpful, as control of infection is usually associated with normalization of the nonspecific markers. Note that some patients are cured despite stubbornly elevated CRP/ESR values, but stopping therapy with high or rising values should always give one pause.



Class Summary

Empiric antimicrobial therapy must be comprehensive and cover all likely pathogens. Antibiotic combinations, usually vancomycin or another MRSA agent plus a broad gram-negative agent, are recommended in both intracranial epidural abscess and spinal epidural abscess while awaiting culture data. This approach ensures coverage for a broad range of organisms and polymicrobial infections. Once organisms and sensitivities are known, antibiotic monotherapy is recommended.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with fair gram-negative and gram-positive activity. Superior CNS penetration. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Does not cover MRSA, Pseudomonas species, or resistant nosocomial enterics.Not a good choice for MSSA-cefazolin, oxacillin or nafcillin preferred.

Ceftazidime (Ceptaz, Fortaz)

Third-generation cephalosporin with broad-spectrum, gram-negative activity (including Pseudomonas species). Poor efficacy against gram-positive organisms and some resistant gram-negative organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Meropenem (Merrem IV)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria, with excellent CNS penetration. Has slightly increased activity against gram-negative bacteria and slightly decreased activity against staphylococci and streptococci compared with imipenem, but much less likely than imipenem to cause seizures.

Metronidazole (Flagyl, Protostat)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Not active against any aerobes. Must be used in combination for most bacterial infections.

Vancomycin (Lyphocin, Vancocin)

Potent antibiotic directed against most gram-positive organisms and active against most Enterococcus species. Indicated in patients who cannot receive or have failed to respond to penicillins and cephalosporins or who have infections with MRSA or another susceptible gram-positive organism.

Nafcillin (Nafcil, Unipen)

A penicillin used almost exclusively for MSSA. Is not effective against MRSA infections. Do not use empirically when MRSA infection is possible.


Cephalosporins, 1st Generation

Cefazolin (Ancef, Kefzol)

First generation cephalosporin with excellent MSSA coverage. No MRSA coverage and poor for many gram-negative organisms, so not used until culture results showing MSSA are in hand.


Cephalosporins, fourth generation

Cefepime (Maxipime)

Excellent gram-negative coverage with fair gram-positive coverage-not useful for MRSA.


Penicillins, Penicillinase-Resistant

Oxacillin (Bactocill)

Similar to nafcillin-used almost exclusively for MSSA. Do not use until cultures positive for MSSA and negative for MRSA as it has no MRSA activity.



Daptomycin (Cubicin, Dapzura RT)

Binds to bacterial membranes and causes depolarization of membrane potential, Active against most gram-positive organisms, but primarily used as as a MRSA drug instead of vancomycin. Resistance can rapidly develop in high innoculum infections, or when prosthetic materials are present.


Cephalosporins, Other