Authors: Jacob Bodilsen, Quintino Giorgio D'Alessandris, Hilary Humphreys...

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

Review

Authors: Dattatraya Muzumdar, Sukhdeep Jhawar, A Goel...

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

Review

Authors: R Sonneville, R Ruimy, N Benzonana...

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

Authors: Leonardo Furtado Freitas, Márcio Luís Duarte, Eduardo Carvalho Miranda...

Topics: Brain Abscess; Humans; Telangiectasia, Hereditary Hemorrhagic

PubMed: 35352758
DOI: 10.1590/0004-282X-ANP-2021-0389

Authors: S Korkmaz, D Korkmaz

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

Review

Authors: Cristina Corsini Campioli, Natalia E Castillo Almeida, John C O'Horo...

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

Authors: Laura Frascheri, Birger Breivik, Rita Helleren...

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

Authors: Junying Huang, Haining Wu, Honghong Huang...

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

Authors: Jacob Bodilsen, Lærke Storgaard Duerlund, Theis Mariager...

BACKGROUND AND OBJECTIVES

Epilepsy in patients with brain abscess is frequent, but risk factors and prognosis remain undetermined. This study examined risk factors of epilepsy among survivors of brain abscess and associated prognosis.

METHODS

Nationwide, population-based healthcare registries were used to compute cumulative incidences and cause-specific adjusted hazard rate ratios (adj. HRRs) with 95% CIs for epilepsy among 30-day survivors of brain abscess from 1982 through 2016. Data were enriched with clinical details by medical record review of patients hospitalized from 2007 through 2016. Adjusted mortality rate ratios (adj. MRRs) were examined using epilepsy as a time-dependent variable.

RESULTS

The study included 1,179 30-day survivors of brain abscess among whom 323 (27%) developed new-onset epilepsy after a median of 0.76 years (interquartile range [IQR] 0.24-2.41). At admission for brain abscess, the median age was 46 years (IQR 32-59) in patients with epilepsy compared with 52 years (IQR 33-64) in those without epilepsy. The proportion of female individuals was similar in patients with and without epilepsy (37%). Adj. HRRs for epilepsy were 2.44 (95% CI 1.89-3.15) for aspiration or excision of brain abscess, 2.37 (1.56-3.60) for alcohol abuse, 1.75 (1.27-2.40) for previous neurosurgery or head trauma, 1.62 (1.17-2.25) for stroke, and 1.55 (1.04-2.32) for age group 20-39 years. Cumulative incidences were increased in patients with alcohol abuse (52% vs 31%), aspiration or excision of brain abscess (41% vs 20%), previous neurosurgery or head trauma (41% vs 31%), and stroke (46% vs 31%). Analysis using clinical details from medical record review of patients from 2007 through 2016 demonstrated adj. HRRs of 3.70 (2.24-6.13) for seizures at admission for brain abscess and 1.80 (1.04-3.11) for frontal lobe abscess. By contrast, adj. HRR was 0.42 (0.21-0.86) for occipital lobe abscess. Using the entire registry-based cohort, patients with epilepsy had an adj. MRR of 1.26 (1.01-1.57).

DISCUSSION

Important risk factors of epilepsy were seizures during admission for brain abscess, neurosurgery, alcoholism, frontal lobe abscess, and stroke. Epilepsy was associated with an increased mortality. Antiepileptic treatment may be guided by individual risk profiles, and a specialized follow-up is highlighted by an increased mortality in survivors with epilepsy.

Topics: Humans; Female; Middle Aged; Young Adult; Adult; Cohort Studies; Alcoholism; Epilepsy; Stroke; Seizures; Risk Factors; Prognosis; Brain Abscess

PubMed: 36810235
DOI: 10.1212/WNL.0000000000206866

Review

Authors: Jingyi Wei, Feiyang Zhong, Lei Sun...

BACKGROUND

The objective of this study is to investigate and understand the characteristics of odontogenic brain abscess.

METHODS

A case of brain abscess suspected to be caused by odontogenic infection was documented, and a comprehensive analysis and summary of odontogenic brain abscess cases reported in various countries over the past 20 years was conducted.

RESULTS

Based on the analysis and synthesis of both the present and previous reports, we have examined and consolidated the distinctive features of odontogenic brain abscess, the potential transmission pathway of pathogenic bacteria, diagnostic assertions, verification techniques, and crucial considerations during treatment.

CONCLUSION

This investigation contributes to an enhanced comprehension and improved clinical identification of odontogenic brain abscess.

Topics: Humans; Brain Abscess; Tooth Diseases

PubMed: 38050225
DOI: 10.1097/MD.0000000000036248