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Clinical Microbiology and Infection :... Jan 2024These European Society of Clinical Microbiology and Infectious Diseases guidelines are intended for clinicians involved in diagnosis and treatment of brain abscess in...
SCOPE
These European Society of Clinical Microbiology and Infectious Diseases guidelines are intended for clinicians involved in diagnosis and treatment of brain abscess in children and adults.
METHODS
Key questions were developed, and a systematic review was carried out of all studies published since 1 January 1996, using the search terms 'brain abscess' OR 'cerebral abscess' as Mesh terms or text in electronic databases of PubMed, Embase, and the Cochrane registry. The search was updated on 29 September 2022. Exclusion criteria were a sample size <10 patients or publication in non-English language. Extracted data was summarized as narrative reviews and tables. Meta-analysis was carried out using a random effects model and heterogeneity was examined by I tests as well as funnel and Galbraith plots. Risk of bias was assessed using Risk Of Bias in Non-randomised Studies - of Interventions (ROBINS-I) (observational studies) and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) (diagnostic studies). The Grading of Recommendations Assessment, Development and Evaluation approach was applied to classify strength of recommendations (strong or conditional) and quality of evidence (high, moderate, low, or very low).
QUESTIONS ADDRESSED BY THE GUIDELINES AND RECOMMENDATIONS
Magnetic resonance imaging is recommended for diagnosis of brain abscess (strong and high). Antimicrobials may be withheld until aspiration or excision of brain abscess in patients without severe disease if neurosurgery can be carried out within reasonable time, preferably within 24 hours (conditional and low). Molecular-based diagnostics are recommended, if available, in patients with negative cultures (conditional and moderate). Aspiration or excision of brain abscess is recommended whenever feasible, except for cases with toxoplasmosis (strong and low). Recommended empirical antimicrobial treatment for community-acquired brain abscess in immuno-competent individuals is a 3rd-generation cephalosporin and metronidazole (strong and moderate) with the addition of trimethoprim-sulfamethoxazole and voriconazole in patients with severe immuno-compromise (conditional and low). Recommended empirical treatment of post-neurosurgical brain abscess is a carbapenem combined with vancomycin or linezolid (conditional and low). The recommended duration of antimicrobial treatment is 6-8 weeks (conditional and low). No recommendation is offered for early transition to oral antimicrobials because of a lack of data, and oral consolidation treatment after ≥6 weeks of intravenous antimicrobials is not routinely recommended (conditional and very low). Adjunctive glucocorticoid treatment is recommended for treatment of severe symptoms because of perifocal oedema or impending herniation (strong and low). Primary prophylaxis with antiepileptics is not recommended (conditional and very low). Research needs are addressed.
Topics: Adult; Child; Humans; Anti-Infective Agents; Brain Abscess; Communicable Diseases
PubMed: 37648062
DOI: 10.1016/j.cmi.2023.08.016 -
International Journal of Surgery... 2011Intracranial abscess is a formidable entity. Despite the advent of newer antibiotics and surgical strategies, the overall outcome and quality of life issues in brain... (Review)
Review
Intracranial abscess is a formidable entity. Despite the advent of newer antibiotics and surgical strategies, the overall outcome and quality of life issues in brain abscess patients still remain a continuous challenge for the neurosurgical community. It is a direct interplay between the virulence of the offending microorganism and the immune response of the host. An analysis of our experience in the 289 cases of surgically treated pyogenic brain abscess is presented along with an overview of intra-cranial abscess of varied etiology and in different locations. The etiology, pathogenesis, radiological advances and treatment modalities of brain abscess are discussed in light of current literature.
Topics: Anti-Bacterial Agents; Anticonvulsants; Brain Abscess; Diffusion Magnetic Resonance Imaging; Humans; Magnetic Resonance Spectroscopy; Neurosurgical Procedures
PubMed: 21087684
DOI: 10.1016/j.ijsu.2010.11.005 -
Clinical Microbiology and Infection :... Sep 2017A brain abscess is a focal infection of the brain that begins as a localized area of cerebritis. In immunocompetent patients, bacteria are responsible for >95% of brain... (Review)
Review
BACKGROUND
A brain abscess is a focal infection of the brain that begins as a localized area of cerebritis. In immunocompetent patients, bacteria are responsible for >95% of brain abscesses, and enter the brain either through contiguous spread following otitis, sinusitis, neurosurgery, or cranial trauma, or through haematogenous dissemination.
AIMS
To identify recent advances in the field.
SOURCES
We searched Medline and Embase for articles published during years 2012-2016, with the keywords 'brain' and 'abscess'.
CONTENT
The triad of headache, fever and focal neurological deficit is complete in ∼20% of patients on admission. Brain imaging with contrast-preferentially magnetic resonance imaging-is the reference standard for diagnosis, and should be followed by stereotactic aspiration of at least one lesion, before the start of any antimicrobials. Efforts should be made for optimal management of brain abscess samples, for reliable microbiological documentation. Empirical treatment should cover oral streptococci (including milleri group), methicillin-susceptible staphylococci, anaerobes and Enterobacteriaceae. As brain abscesses are frequently polymicrobial, de-escalation based on microbiological results is safe only when aspiration samples have been processed optimally, or when primary diagnosis is endocarditis. Otherwise, many experts advocate for anaerobes coverage even with no documentation, given the sub-optimal sensitivity of current techniques. A 6-week combination of third-generation cephalosporin and metronidazole will cure most cases of community-acquired brain abscess in immunocompetent patients.
IMPLICATIONS
Significant advances in brain imaging, minimally invasive neurosurgery, molecular biology and antibacterial agents have dramatically improved the prognosis of brain abscess in immunocompetent patients over the last decades.
Topics: Anti-Infective Agents; Brain Abscess; Drainage; Humans; Neurosurgical Procedures
PubMed: 28501669
DOI: 10.1016/j.cmi.2017.05.004 -
Arquivos de Neuro-psiquiatria Feb 2022
Topics: Brain Abscess; Humans; Telangiectasia, Hereditary Hemorrhagic
PubMed: 35352758
DOI: 10.1590/0004-282X-ANP-2021-0389 -
Clinical Microbiology and Infection :... Sep 2023Early switch to oral antimicrobials has been suggested as a treatment strategy in patients with brain abscess, but the practice is controversial. (Review)
Review
BACKGROUND
Early switch to oral antimicrobials has been suggested as a treatment strategy in patients with brain abscess, but the practice is controversial.
OBJECTIVES
This review aimed to summarize the background, current evidence, and future perspectives for early transition to oral antimicrobials in patients with brain abscess.
SOURCES
The review was based upon a previous systematic review carried out during the development of the ESCMID guidelines on diagnosis and treatment of brain abscess. The search used 'brain abscess' or 'cerebral abscess' as text or MESH terms in PubMed, EMBASE, and the Cochrane Library. Studies included in the review were required to be published in the English language within the last 25 years and to have a study population of ≥10 patients. Other studies known by the authors were also included.
CONTENT
In this review, the background for some experts to suggest early transition to oral antimicrobials in patients with mild and uncomplicated brain abscess was clarified. Next, results from observational studies were summarized and limitations discussed. Indirect support for early oral treatment of brain abscess was described with reference to other serious central nervous system infections and general pharmacological considerations. Finally, variations within and between countries in the use of early transition to oral antimicrobials in patients with brain abscess were highlighted.
IMPLICATIONS
Early transition to oral antimicrobials in patients with uncomplicated brain abscess may be of benefit for patients due to convenience of treatment and potential decreased risks associated with prolonged hospitalization and intravenous lines. The strategy may also confer a more rational allocation of healthcare resources and decrease expenses. However, the benefit/risk ratio for this strategy remains unresolved at present.
Topics: Humans; Anti-Infective Agents; Brain Abscess; Administration, Intravenous; Brain
PubMed: 37119987
DOI: 10.1016/j.cmi.2023.04.026 -
International Journal of Infectious... Feb 2022Differences in management and outcomes of brain abscesses due to gram-positive (GPB) versus gram-negative bacteria (GNB) are not well defined. (Review)
Review
OBJECTIVES
Differences in management and outcomes of brain abscesses due to gram-positive (GPB) versus gram-negative bacteria (GNB) are not well defined.
METHODS
A retrospective review of adult patients with brain abscesses due to monomicrobial infection from 2009 through 2020 was performed.
RESULTS
A total 177 patients had a monomicrobial brain abscess; 143 (80.8%) caused by GPB and 34 (19.2%) by GNB. Patients with GNB had more history of head/neck surgery than those with GPB (58.8% vs 36.4%; P = 0.02). Pathogens in the GNB group included Pseudomonas aeruginosa (29.4%), Klebsiella spp (20.6%), and Enterobacter spp (20.6%). Pathogens in the GPB group included Staphylococcus aureus (32.2%) and Streptococcus spp (31.5%). Most patients had combined medical/surgical management (64.7% GNB vs 63.6% GPB). The median duration of antibiotic therapy was 42 days, and there was no significant difference in infection relapse or 3-month survival rate. Patients with GNB were more likely to have therapeutic failure than those with GPB (44.1% vs 22.4%; P = 0.01).
CONCLUSIONS
Compared with brain abscesses caused by GPB, those due to GNB were more likely to occur in patients who had undergone prior head and neck surgery . No statistically significant difference in outcomes was observed between the groups; however, patients with GNB had a higher therapeutic failure rate than those with GPB.
Topics: Adult; Anti-Bacterial Agents; Bacteremia; Brain Abscess; Gram-Negative Bacteria; Gram-Negative Bacterial Infections; Gram-Positive Bacteria; Humans; Retrospective Studies
PubMed: 34902581
DOI: 10.1016/j.ijid.2021.12.322 -
European Review For Medical and... Oct 2023Brain abscess, a localized purulent central nervous system infection, arises from a variety of microorganisms. Expedited diagnosis and formulation of effective treatment...
OBJECTIVE
Brain abscess, a localized purulent central nervous system infection, arises from a variety of microorganisms. Expedited diagnosis and formulation of effective treatment strategies are crucial for mitigating mortality risks in patients with brain abscesses. A nuanced understanding of potential microbial agents is pivotal for the development of empirical antibiotic therapies. This study aimed to explore the incidence and microbial etiology of brain abscesses.
PATIENTS AND METHODS
This study is a nationwide cross-sectional analysis of patients diagnosed with brain abscesses in Turkey, employing the ICD 10 diagnosis code from January 1, 2015, to December 31, 2021. Data pertaining to age, sex, comorbidities, and microorganisms isolated from central nervous system samples were meticulously recorded and analyzed.
RESULTS
This study included 11,536 patients diagnosed with brain abscesses. The incidence fluctuated between 0.98 and 3.68 during the review decrease post-2017, with a notable increase in male patients during time. Diabetes constituted 56.5% of the patients. The predominant isolated pathogens were Staphylococcus (37.6%), Streptococci (13.3%), and Klebsiella spp. (7.8%), Escherichia coli (6.4%), and Candida species (6.1%).
CONCLUSIONS
The incidence of brain abscesses is decreasing in Turkey. Although staphylococci remain the most isolated agents, the frequent occurrence of Gram-negative bacteria and Candida species warrants consideration during empirical antibiotic selection.
Topics: Humans; Male; Cross-Sectional Studies; Incidence; Turkey; Anti-Bacterial Agents; Staphylococcus; Brain Abscess; Microbial Sensitivity Tests; Retrospective Studies
PubMed: 37916333
DOI: 10.26355/eurrev_202310_34140 -
Tidsskrift For Den Norske Laegeforening... Apr 2021The diagnosis of intracerebral fungal abscesses may be difficult due to the paucity of laboratory tests and similar radiological appearance to other lesions.
BACKGROUND
The diagnosis of intracerebral fungal abscesses may be difficult due to the paucity of laboratory tests and similar radiological appearance to other lesions.
CASE PRESENTATION
We present an immunocompromised woman in her forties who was admitted with a diagnosis of bacterial meningitis. MRI examination showed findings suggestive of fungal abscesses, and a subsequent lumbar puncture showed PCR positive for non-fumigatus Aspergillus. The patient received antifungal treatment and had satisfactory clinical, biochemical and radiological response. Consecutive MRI examinations over the following weeks showed gradual decrease of abscesses, with almost complete resolution within 12 weeks.
INTERPRETATION
Adequate management of brain abscesses requires correct identification of the causative agent, so that proper treatment can be initiated as soon as possible. MRI plays an important role in distinguishing between pyogenic and fungal brain abscesses. Headaches or focal neurological deficits in immunocompromised patients should cause CNS fungal infection to be considered.
Topics: Antifungal Agents; Aspergillosis; Brain Abscess; Female; Headache; Humans; Magnetic Resonance Imaging
PubMed: 33876620
DOI: 10.4045/tidsskr.20.0825 -
BMC Infectious Diseases Dec 2021Patients with primary brain abscess often present with atypical symptoms, and the outcome varies. We investigated the demographic, laboratory, and neuroimaging features...
BACKGROUND
Patients with primary brain abscess often present with atypical symptoms, and the outcome varies. We investigated the demographic, laboratory, and neuroimaging features of patients with brain abscess at our hospital and identified factors associated with their outcomes.
METHODS
We retrospectively collected the data of patients diagnosed with primary brain abscess at our hospital between January 2011 and December 2020. Their clinical characteristics, predisposing factors, laboratory and neuroimaging findings, treatment, and outcome were analyzed.
RESULTS
Of the 57 patients diagnosed with primary abscess, 51 (89.47%) were older than 40 years, and 42 (73.68%) were male. Only eight patients (14.04%) showed the classical triad of headache, fever, and focal neurological deficit. Fifteen patients (26.31%) had comorbidities, of which diabetes mellitus was the most common. Positive intracranial purulent material cultures were obtained in 46.15% of the patients, and gram-negative enteric bacteria were found in 33.33% of them, with Klebsiella pneumoniae being the most frequently observed. Surgical treatment, most commonly in the form of stereotactic drainage, was received by 54.39% of the patients. Good outcomes were achieved in 75.44% of the patients. Multivariate logistic regression analysis showed that patients with headaches were more likely to have a poor outcome (odds ratio 6.010, 95% confidence interval 1.114-32.407, p = 0.037).
CONCLUSIONS
Male patients and those older than 40 years were more susceptible to brain abscess than female patients and those younger than 40 years, respectively. Only a few patients showed the classical triad of clinical symptoms. Diabetes mellitus was the most common comorbidity. Positive intracranial specimens' culture results were uncommon, with gram-negative enteric bacteria, especially Klebsiella pneumoniae, being the main organisms found. Most patients had a good outcome, and the presence of headache may influence the outcome.
Topics: Brain Abscess; Comorbidity; Female; Humans; Klebsiella pneumoniae; Male; Odds Ratio; Retrospective Studies
PubMed: 34903183
DOI: 10.1186/s12879-021-06947-2 -
Child's Nervous System : ChNS :... Dec 2020Brainstem abscess is a rare condition accounting for merely 1% of brain abscesses incidence in the pediatric population. This study aimed to present a single patient... (Review)
Review
PURPOSE
Brainstem abscess is a rare condition accounting for merely 1% of brain abscesses incidence in the pediatric population. This study aimed to present a single patient with a pontine abscess and review the literature to highlight clinical features, diagnosis, and management of brainstem abscess.
METHODS
The PubMed database was screened for English-language articles concerning pediatric brainstem abscess. We, therefore, identified 22 publications, which concisely depict 23 cases. Our study reports on the 24th pediatric patient diagnosed with that entity. All included reports were analyzed in terms of clinical presentation, diagnosis, management, and outcomes of described patients.
RESULTS
There was slight women predominance (15:9), with a mean age of occurrence 6.4 years, ranging from 7 months to 16 years. Pons was the most common location of brainstem abscess, occurring in 75% of patients. Clinically, they mostly presented with cranial nerves palsy (79.2%), hemiparesis (66.7%), and pyramidal signs (45.8%). The classic triad of symptoms, including fever, headache, and the focal neurologic deficit was present in 20.8% of patients. Positive pus cultures were obtained in 61.1%. Streptococci and Staphylococci were the most frequently identified pus microorganisms. Outcomes were satisfactory, with a 79.2% rate of general improvement.
CONCLUSIONS
Neurosurgical aspiration is a safe and beneficial therapeutic method. It should always be considered and should promptly be performed when the conservative treatment is not successful and clinical deterioration occurs. Prognosis in pediatric brainstem abscess is generally favorable. Most patients recover with minor neurologic deficits or improve completely.
Topics: Brain Abscess; Child; Female; Humans; Pons
PubMed: 32734403
DOI: 10.1007/s00381-020-04835-9