Epidural Infections (Spinal Epidural Abscess) and Subdural Infections (Subdural Empyema) Medication

Updated: Jul 19, 2019
  • Author: Hina Z Ghory, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Medication Summary

Initiate antibiotic treatment as soon as possible in conjunction with surgical therapy.



Class Summary

S aureus is a common pathogen in these conditions, although subdural empyema is often polymicrobial with streptococcal species. Methicillin-resistant S aureus (MRSA) should be suspected pending definitive results.

Recent clinical practice guidelines for treatment of MRSA have been published. [18]

Antistaphylococcal therapy should also be included in any regimen. For spinal epidural abscess, vancomycin can be used pending culture results. For subdural empyema, recommendations vary, but reasonable empiric therapy would include vancomycin, a third-generation cephalosporin, and metronidazole pending bacterial identification with drug sensitivities. Linezolid has been reported as effective in a few cases of recurrent streptococcal subdural empyema that failed to respond to conventional antibiotic therapy. [19]

Ceftriaxone (Rocephin)

A third-generation cephalosporin that has a broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.

By binding to one or more penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.

Nafcillin (Unipen)

Treats infections caused by penicillinase-producing staphylococci. Used to initiate therapy in any patient whom a penicillin G-resistant staphylococcal infection is suspected. Do not use for treatment of penicillin G-susceptible Staphylococcus.

Use parenteral therapy initially in severe infections. Very severe infections may require very high doses. Change to PO as condition improves.

Because of occasional occurrence of thrombophlebitis associated with the parenteral route, particularly in elderly patients, administer parenterally only for a short term (24-48 h) and change to PO if clinically possible.

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, binds DNA, and inhibits protein synthesis, causing cell death.

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who can not 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, anaerobes, or both.

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.