Medication Summary
Antibiotic therapy ideally is started after appropriate cultures but should not be delayed if difficulties exist in obtaining specimens. Antibiotics selected should be broad-spectrum, particularly active against S aureus, and capable of achieving high levels in the cerebrospinal fluid. With the recent increased prevalence of community-acquired MRSA, the emergency physician should consider additional coverage with intravenous antibiotics, such as vancomycin, if MRSA infection is suspected.
However, a case report and literature review by Naesens et al of community-acquired MRSA infections of the central nervous system, including cavernous sinus thrombosis, showed that patients treated with linezolid had a better outcome than those treated with vancomycin. [13]
Antibiotic, Miscellaneous
Class Summary
Empiric broad-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms is necessary. Therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
In cases of suspected MRSA infection, vancomycin should be added for additional coverage.
Oxacillin (Bactocill)
A bactericidal antibiotic that inhibits cell wall synthesis. Used in treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when staphylococcal infection is suspected.
Ceftriaxone (Rocephin)
Alternate antimicrobial choice. Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms than earlier generation cephalosporins. By binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
Metronidazole (Flagyl)
Additional anaerobic coverage. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually employed in combination with other antimicrobial agents (except when used for Clostridium difficile enterocolitis, in which monotherapy appropriate).
Chloramphenicol (Chloromycetin)
Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Vancomycin
Indicated for patients who cannot 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 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 diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin allergic patients undergoing gastrointestinal or genitourinary procedures.
Anticoagulants
Class Summary
Unfractionated IV heparin and fractionated low-molecular-weight SC heparins are the 2 options in anticoagulation therapy.
Heparin
Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse thrombus but able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis. Various dosing nomograms available.
Corticosteroids
Class Summary
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli. When the course of CST leads to pituitary insufficiency, corticosteroids definitely are indicated to prevent adrenal crisis.
Hydrocortisone (Solu-Cortef, Westcort)
DOC due to its mineralocorticoid activity and glucocorticoid effects. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Useful in management of inflammation caused by an immune response.
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Anatomy of cross section of cavernous sinus showing close proximity to cranial nerves and sphenoid sinus.
