Prehospital Care
Supportive care, including intravenous access, fluid resuscitation, oxygen, and monitoring, as indicated.
Emergency Department Care
Stabilization procedures may be needed. Most efforts are directed at examination and appropriate imaging for definitive diagnosis. Do not delay antibiotic therapy for imaging procedures or other workup in toxic patients or in those patients with a high likelihood of these disorders or when meningitis remains a possibility in the differential diagnosis. For nontoxic and stable patients, antibiotic therapy is ideally guided by results of abscess aspiration or drainage.
Spinal epidural abscess
Treatment is medical and surgical, with surgery frequently necessary if signs of spinal cord compression are present.
Empiric antibiotic coverage should include an antistaphylococcal penicillin or a cephalosporin.
Empirical antibiotic therapy in most cases should provide coverage against MRSA with vancomycin. [5]
Subdural empyema
Immediate surgical evacuation of the empyema is necessary.
Some controversy exists as to whether a craniotomy flap or multiple burr holes are the superior therapy.
Antibiotic therapy against S aureus, the most common pathogen, is necessary.
If a neurosurgical procedure has recently occurred, combination therapy, as described above, is recommended.
Seizure treatment or prophylaxis may be indicated, depending on the clinical situation.
Consultations
Expeditious neurosurgical consultation should be initiated when either of these entities is suspected.
Prevention
To decrease the likelihood of spinal epidural abscesses, high-risk neurosurgical procedures must be performed using strict sterile surgical techniques. Efforts to reduce injection drug use will also decrease spinal epidural abscesses from hematogenous spread.
Appropriate and early treatment of sinus and otic infections, prior to invasion into bone, will reduce the occurrence of subdural empyema.
Further Inpatient Care
Spinal epidural abscess: Once diagnosed, further inpatient and outpatient care will be under the direction of the neurosurgeon and/or infectious disease consultant. Generally, if signs of spinal cord compression are present, the treatment includes prompt surgical drainage with antibiotic treatment. If spinal cord compression is not present, some advocate CT-guided abscess aspiration and a prolonged antibiotic course or antibiotic medication alone. Patients must be carefully monitored, and immediate surgical decompression is recommended should neurologic dysfunction develop.
Up to 30%-41% of spinal epidural abscesses fail medical management. [17] Several factors may contribute to failure of medical management, including delayed diagnosis, anatomical location of the abscess, timing and type of antibiotic used, virulence of the causative organism, and patient age and health status, including the presence of diabetes. Factors such as age (>65 years), neurological impairment, MRSA infections, a white blood cell count of more than 12,000/µL, C-reactive protein level more than 115 mg/L, and positive blood culture results have been shown to correlate with failure of medical management. [17]
Subdural empyema: Immediate surgical evacuation is recommended as discussed above. Initiate antibiotic therapy as early as possible and continue through the postoperative period. Antibiotics and duration are at the discretion of the admitting physician.
Transfer
Transfer to a facility with appropriate resources (neurosurgical and neuroimaging), if necessary. If these infections are suspected, antibiotic therapy should be initiated prior to transfer. Physician-to-physician contact is necessary to coordinate care.
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Spinal epidural abscess with cord edema and compression. Abscess extends into paravertebral tissues.
