Brain abscess
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
presumed brain abscess
empiric antibiotic therapy
Antibiotics are the first line of treatment and should be started immediately unless the patient is to be taken to the operating room, in which case antibiotics are held until aspiration of the lesion contents yields a sample for culture.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours
-- AND --
metronidazole: 500 mg intravenously every 6 hours
or
clindamycin: 900 mg intravenously every 8 hours
-- AND --
ceftriaxone: 2 g intravenously every 12 hours
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface.
Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
corticosteroid
Additional treatment recommended for SOME patients in selected patient group
Corticosteroids cause rapid reduction in vasogenic oedema associated with cerebral abscesses, and may be used in the acutely decompensating patient as a life-saving measure. However, their use in the treatment of acute infection or sepsis is controversial.
Dexamethasone is generally used when corticosteroid treatment is warranted.
Primary options
dexamethasone: 10 mg intravenously as a single dose, followed by 4-6 mg orally every 6 hours
urgent surgical decompression
Additional treatment recommended for SOME patients in selected patient group
In patients with neurological decompensation, urgent surgical decompression is required.
Surgical intervention offers the advantages of decreasing the infectious burden, obtaining a sample for culture, confirming the diagnosis by sampling the capsular tissue, and relieving the mass effect in the acutely deteriorating patient.
Surgery carries the risk of spread of the infectious agent to the ventricular system, resulting in ventriculitis.
suspected or confirmed bacterial aetiology
continued antibiotic therapy
The duration of antibiotic treatment is variable, but generally patients are treated for 6 to 8 weeks, with serial neuro-imaging performed to ensure a beneficial treatment response.
Antibiotics are tailored to specific aetiological agents when possible.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours
-- AND --
metronidazole: 500 mg intravenously every 6 hours
or
clindamycin: 900 mg intravenously every 8 hours
-- AND --
ceftriaxone: 2 g intravenously every 12 hours
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface. Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
surgical evacuation
Additional treatment recommended for SOME patients in selected patient group
Surgery along with antibiotic therapy is the first line of treatment for pyogenic abscesses >2.5 cm in the largest dimension, and the second line of treatment for smaller abscesses that prove refractory to medical therapy.
Surgical evacuation offers the advantages of decreasing the infectious burden, obtaining a sample for culture, confirming the diagnosis by sampling the capsular tissue, and relieving the mass effect in the acutely deteriorating patient.
Surgery carries the risk of spread of the infectious agent to the ventricular system, resulting in ventriculitis.
Generally, lesions are treated with aspiration, reserving open surgery for recurrent lesions or lesions in the cerebellum.
confirmed fungal aetiology
antifungal therapy
Antifungal agents in general have particularly poor penetration across the blood-brain barrier, and medical therapy alone is rarely indicated for fungal brain abscesses.
Liposomal amphotericin B crosses the blood-brain barrier well and is the preferred amphotericin preparation.
Treatment course: the duration of antifungal treatment is variable, but generally patients are treated for 6 to 8 weeks, with serial neuro-imaging performed to ensure a beneficial treatment response.
Primary options
amphotericin B liposomal: consult specialist for guidance on dose
OR
fluconazole: 400 mg intravenously once daily
OR
caspofungin: 70 mg intravenously as a single dose on day 1, followed by 50 mg once daily
surgical evacuation
Treatment recommended for ALL patients in selected patient group
Patients are treated with antibiotics until fungal abscess is suspected or confirmed. Antifungal agents are then tailored to the aetiological agent.
Surgical evacuation offers the advantages of decreasing the infectious burden, obtaining a sample for culture, confirming the diagnosis by sampling the capsular tissue, and relieving the mass effect in the acutely deteriorating patient.
Surgery carries the risk of spread of the infectious agent to the ventricular system, resulting in ventriculitis.
Open surgery is recommended because the penetration of antifungal agents across the blood-brain barrier is poor.[3]Hall WA, Truwit CL. The surgical management of infections involving the cerebrum. Neurosurgery. 2008 Feb;62(2 suppl):519-30. http://www.ncbi.nlm.nih.gov/pubmed/18596452?tool=bestpractice.com
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface. Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
antifungal therapy
Antifungal agents in general have particularly poor penetration across the blood-brain barrier, and medical therapy alone is rarely indicated for fungal brain abscesses.
Flucytosine is contraindicated in patients with known complete dihydropyrimidine dehydrogenase (DPD) deficiency due to the risk of life-threatening drug toxicity. Patients with a partial DPD deficiency are also at increased risk of severe toxicity. Although pretesting of DPD status is not required, consider determination of DPD activity if drug toxicity is confirmed or suspected.
Liposomal amphotericin B crosses the blood-brain barrier well and is the preferred amphotericin preparation.
Treatment course: the duration of antifungal treatment is variable, but generally patients are treated for 6 to 8 weeks, with serial neuro-imaging performed to ensure a beneficial treatment response.
Primary options
amphotericin B liposomal: consult specialist for guidance on dose
-- AND --
flucytosine: 150 mg/kg/day orally given in divided doses every 6 hours
or
fluconazole: 400 mg intravenously once daily
surgical evacuation
Treatment recommended for ALL patients in selected patient group
Patients are treated with antibiotics until fungal abscess is suspected or confirmed. Antifungal agents are then tailored to the aetiological agent.
Surgical evacuation offers the advantages of decreasing the infectious burden, obtaining a sample for culture, confirming the diagnosis by sampling the capsular tissue, and relieving the mass effect in the acutely deteriorating patient.
Surgery carries the risk of spread of the infectious agent to the ventricular system, resulting in ventriculitis.
Open surgery is recommended because the penetration of antifungal agents across the blood-brain barrier is poor.[3]Hall WA, Truwit CL. The surgical management of infections involving the cerebrum. Neurosurgery. 2008 Feb;62(2 suppl):519-30. http://www.ncbi.nlm.nih.gov/pubmed/18596452?tool=bestpractice.com
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface. Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
antifungal therapy
Antifungal agents in general have particularly poor penetration across the blood-brain barrier, and medical therapy alone is rarely indicated for fungal brain abscesses.
Liposomal amphotericin B crosses the blood-brain barrier well and is the preferred amphotericin preparation.
Treatment course: the duration of antifungal treatment is variable, but generally patients are treated for 6 to 8 weeks, with serial neuro-imaging performed to ensure a beneficial treatment response.
Primary options
amphotericin B liposomal: consult specialist for guidance on dose
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface. Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
surgical evacuation
Additional treatment recommended for SOME patients in selected patient group
Patients are treated with antibiotics until fungal abscess is suspected or confirmed. Antifungal agents are then tailored to the aetiological agent.
Surgical evacuation offers the advantages of decreasing the infectious burden, obtaining a sample for culture, confirming the diagnosis by sampling the capsular tissue, and relieving the mass effect in the acutely deteriorating patient.
Surgery carries the risk of spread of the infectious agent to the ventricular system, resulting in ventriculitis.
Open surgery is recommended because the penetration of antifungal agents across the blood-brain barrier is poor.[3]Hall WA, Truwit CL. The surgical management of infections involving the cerebrum. Neurosurgery. 2008 Feb;62(2 suppl):519-30. http://www.ncbi.nlm.nih.gov/pubmed/18596452?tool=bestpractice.com
Liposomal amphotericin B has increased permeability across the blood-brain barrier and has been used to treat Aspergillus non-surgically, although A. fumigatus and Mucormycosis species abscesses are still best treated with surgery followed by antifungal therapy.
suspected or confirmed parasitic aetiology
antiparasitics
Patients are treated with antibiotics until parasitic disease is suspected or confirmed.
As with bacterial brain abscesses, selection of the appropriate antimicrobial agent is the first line of treatment.
The duration of antiparasitic treatment is variable, but generally patients are treated for 6 to 8 weeks, with serial neuro-imaging performed to ensure a beneficial treatment response.
Primary options
pyrimethamine: 200 mg orally as a single dose on day 1, followed by 75 mg orally once daily
and
sulfadiazine: 1500 mg orally four times daily
OR
trimethoprim/sulfamethoxazole: 5 mg/kg orally twice daily
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim component.
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface. Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
antiretroviral therapy (ART)
Additional treatment recommended for SOME patients in selected patient group
If toxoplasmosis is the presentation of newly diagnosed HIV, or if the patient has untreated HIV infection, rapid commencement of antiretroviral therapy (ART) is mandatory and may lead to resolution of the toxoplasma infection.
praziquantel
Treatment of brain abscesses caused by parasitic infections is highly specific to the agent isolated.
Treatment course: the duration of antiparasitic treatment is variable, but generally patients are treated for 6 to 8 weeks, with serial neuro-imaging performed to ensure a beneficial treatment response.
Primary options
praziquantel: 50 mg/kg/day orally given in 3 divided doses
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface. Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
amphotericin B
Liposomal amphotericin B crosses the blood-brain barrier well and is the preferred amphotericin preparation.
The duration of treatment is variable, but generally patients are treated for 6 to 8 weeks, with serial neuro-imaging performed to ensure a beneficial treatment response. However, the infection is usually fatal.
Primary options
amphotericin B liposomal: consult specialist for guidance on dose
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface. Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
cryptogenic brain abscess
continued antibiotic therapy
The duration of antibiotic treatment is variable, but generally patients are treated for 6 to 8 weeks, with serial neuro-imaging performed to ensure a beneficial treatment response.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours
-- AND --
metronidazole: 500 mg intravenously every 6 hours
or
clindamycin: 900 mg intravenously every 8 hours
-- AND --
ceftriaxone: 2 g intravenously every 12 hours
anticonvulsant
Additional treatment recommended for SOME patients in selected patient group
Prophylaxis with anticonvulsants should be considered for patients who have had a seizure or those with an abscess near the motor cortex or the brain surface. Routine anticonvulsant prophylaxis is not recommended.[5]Brouwer MC, Tunkel AR, McKhann GM 2nd, et al. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. http://www.ncbi.nlm.nih.gov/pubmed/25075836?tool=bestpractice.com There are no studies of anticonvulsant prophylaxis in patients with brain abscess, and anticonvulsant prophylaxis does not reduce the risk of seizures in patients with brain tumours.[44]Tremont-Lukats IW, Ratilal BO, Armstrong T, et al. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/18425902?tool=bestpractice.com
Levetiracetam is typically used when anticonvulsant prophylaxis is indicated. It is generally well tolerated and is associated with fewer drug-drug interactions than other anticonvulsants.
Primary options
levetiracetam: consult specialist for guidance on dose
surgical evacuation
Additional treatment recommended for SOME patients in selected patient group
Surgery along with antibiotic therapy is the first line of treatment for pyogenic abscesses >2.5 cm in the largest dimension, and the second line of treatment for smaller abscesses that prove refractory to medical therapy.
Surgical evacuation offers the advantages of decreasing the infectious burden, obtaining a sample for culture, confirming the diagnosis by sampling the capsular tissue, and relieving the mass effect in the acutely deteriorating patient.
Surgery carries the risk of spread of the infectious agent to the ventricular system, resulting in ventriculitis.
Generally, lesions are treated with aspiration, reserving open surgery for recurrent lesions or lesions in the cerebellum.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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