Initial Management at Presentation
- No definitive guidance: There have been no randomized, controlled trials of the various treatments for brain abscesses. Available information for treatment options is therefore not based on Class I data. A specimen of the pus is essential for accurate identification of the organism so that the appropriate antibiotic therapy can be commenced.
- Clinical picture guides treatment: The management of brain abscesses may be influenced by the neurological status of the patient, the location of the abscess, the number and size of the abscesses, and the stage of abscess formation (23, 91, 94).
- Medical management with antibiotics: Medical management alone is considered for cerebritis, small abscesses, and multiple abscesses and for patients who are not good surgical candidates.
- Surgical management: Surgical treatment of abscesses is preferred when the abscesses are large (> 2.5 cm diameter), mature by radiological criteria, or associated with clinical signs of mass effect.
- Steroids controversial: Steroids adversely affect the natural maturation of cerebritis into an abscess, the antibiotic penetration into the infection, and the body’s immune system (55, 128, 130). Their use is recommended only for critically ill patients suffering from the mass effect of extensive edema surrounding a formed abscess (88, 118).
- Anticonvulsant use not proven: There are no studies available to provide guidance in deciding whether or not to use anticonvulsants (31).
- 4–6 weeks of intravenous antibiotics: While there is no proven duration of need for antibiotics, most recommend a 4–6 week course of intravenous antibiotics in immunocompetent patients and a longer course for those who are immuncompromised (31).
- Bimonthly imaging until resolution: Progressive improvement in imaging is expected after the initiation of antibiotic treatment. Imaging is recommended every 2 weeks until the abscess has resolved and then every 3–4 months for a year to insure recognition of recurrence (55, 118).
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