Indications for Nonsurgical Treatment
- Definitive medical management of abscesses more difficult: Antibiotics alone can fail to cure the infection because the extent to which they cross the blood–brain barrier, permeate the abscess capsule, and diffuse into devitalized purulent tissue is usually restricted. As a consequence, they can be ineffective in eradicating the infectious reservoir (92). Additionally, antibiotics can be inactivated by bacterial enzymes, by proteins present in pus fluid that can bind to them, or by the pH of this material (84).
- Small abscesses <2.5 cm diameter: The diameters of abscesses successfully treated with antibiotics alone were 0.8-2.5 cm (mean 1.7 cm) in one series (128).
- Cerebritis: A patient with symptoms that have been present for less than 2 weeks and a scan that does not show the typical hypodense area of necrosis seen with abscesses can be considered to be in the early cerebritis stage. These patients can be considered for medical management alone (30, 103).
- Poor surgical candidate: A patient with multiple abscesses or with an abscess in an inaccessible region of the brain is difficult to manage surgically, and most will at least attempt initial medical management (30, 103). Additionally, patients with concomitant meningitis or ependymitis and patients with high-risk medical comorbidities are usually managed medically (30, 103).
- Treatment design by multidisciplinary team: Brain abscesses in children should be managed by a multidisciplinary team that includes neurosurgeons and infectious disease practitioners. This team approach is important for tailoring the best policy for diagnosis, treatment, and follow-up.
- Initial broad-spectrum antibiotics: Empiric antibiotic treatment with broad-spectrum agents is usually started until intraoperative cultures can be obtained, allowing tailoring of the antimicrobial agents to the identified pathogens. Typically this consists of a third-generation cephalosporin and metronidazole. Therapy can be narrowed once the source for the infection has been identified or if a specific organism or organisms are identified (31). It is difficult to isolate anaerobic bacteria even if they are part of the microbiological composition of the cerebral abscess, so anaerobic coverage is often maintained if only one organism is identified in the culture.
Duration of Treatment
- 8 weeks of intravenous treatment: The duration of antimicrobial therapy is typically 8 weeks without surgical intervention and 4–8 weeks with surgical intervention (55). There are no prospective studies in children to guide the duration of antimicrobial therapy; however, in immunocompetent hosts intravenous antimicrobial courses are favored at least 4–6 weeks in duration and longer in immunosuppressed patients (31).
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