さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist. Another face is an investor.

脳膿瘍を復習

緊急ドレナージした脳膿瘍の患者さんについて、脳外科医の先生とディスカッションしエンピリック開始。

 

脳膿瘍は初めてだったので、抗菌薬選択を調べてみました。

 

 

基本として、中枢神経系の移行が期待できない抗菌薬はさける。

 

 第1、2世代セフェム系、アミノグリコシド系、マクロライド系、クリンダマイシン

 

 

 

 

Up To Date から

 

脳膿瘍 

 

SUMMARY AND RECOMMENDATIONS

 

●Successful management of a brain abscess usually requires a combination of antibiotics and surgical drainage.

 

●The neurosurgeon needs to be contacted at the time of initial diagnosis of a brain abscess. Aspiration or surgical drainage generally is required for both diagnosis and treatment. 

 

●We recommend empiric antimicrobial therapy for all patients with a presumptive brain abscess (Grade 1B). Antimicrobial therapy should be administered as soon as possible, although preferably after diagnostic aspiration. The empiric antibiotic regimen is based upon the presumptive source of the abscess and Gram stain results if available.

 

●When the etiologic agent(s) has been identified by culture, we recommend treatment regimens be simplified and directed to that pathogen(s) (Grade 1B).

 

●We recommend treatment for at least four to eight weeks, guided by follow-up assessment of clinical course and imaging studies for substantial improvement of computed tomographic scan findings (Grade 1B).

 

●We suggest glucocorticoids be used only when substantial mass effect can be demonstrated on a scan and the mental status is significantly depressed (Grade 2C). 

 

●Mortality from brain abscess ranges from 0 to 30 percent.

 

●Neurologic sequelae, of which seizures are the most common, occur in 30 to 60 percent of patients. 

 

 

Empiric therapy 

 

We recommend that the empiric antimicrobial regimen be based on the presumptive source of the abscess and Gram stain results if available. The antibiotic doses recommended below are intended for patients with normal renal function; dosing of many of these agents must be reduced in patients with renal dysfunction.

For patients with a brain abscess arising from an oral, otogenic, or sinus source (eg, chronic otitis or mastoiditis, where the site of abscess is usually the temporal lobe or cerebellum; or frontal or ethmoid sinusitis, where the site of abscess is usually the frontal lobe), we recommend treatment with:

Metronidazole (15 mg/kg [usually 1 g] intravenously [IV] as a loading dose, followed by 7.5 mg/kg [usually 500 mg] IV every eight hours) PLUS either penicillin G (20 to 24 million units per day IV in six equally divided doses) for a suspected oral focus OR ceftriaxone (2 g IV every 12 hours) or cefotaxime (2 g IV every four to six hours) for a suspected sinus or otogenic source.

 

For patients with a brain abscess from hematogenous spread (eg, bacteremia or endocarditis with multiple abscesses in middle cerebral artery distribution), we recommend treatment with:

Vancomycin (15 to 20 mg/kg per dose IV every 8 to 12 hours, not to exceed 2 g per dose) for empiric coverage of MRSA. If susceptibility testing reveals methicillin-sensitive S. aureus, vancomycin should be replaced with nafcillin (2 g IV every four hours) or oxacillin (2 g IV every four hours). Metronidazole and ceftriaxone or cefotaxime, dosed as above, may be added for initial empiric coverage if the bacteriology is uncertain.

 

For brain abscess in postoperative neurosurgical patients, we recommend treatment with:

Vancomycin (15 to 20 mg/kg per dose IV every 8 to 12 hours, not to exceed 2 g per dose) PLUS ceftazidime (2 g IV every eight hours), cefepime (2 g IV every eight hours), or meropenem (2 g IV every eight hours). If meropenem is not available, imipenem (500 mg or 1 g IV every six hours) can be used as an alternative agent. If both agents are available, we prefer meropenem since imipenem may increase the risk of seizures. If susceptibility testing reveals methicillin-sensitive S. aureus, vancomycin should be replaced with nafcillin (2 g IV every four hours) or oxacillin (2 g IV every four hours).

 

For brain abscess following penetrating trauma, we recommend treatment with:

Vancomycin (15 to 20 mg/kg per dose IV every 8 to 12 hours, not to exceed 2 g per dose) PLUS either ceftriaxone (2 g IV every 12 hours) or cefotaxime (2 g IV every four to six hours). If susceptibility testing reveals methicillin-sensitive S. aureus, vancomycin should be replaced with nafcillin (2 g IV every four hours) or oxacillin (2 g IV every four hours). If the paranasal sinuses are involved, add metronidazole (15 mg/kg [usually 1 g] IV as a loading dose, followed by 7.5 mg/kg [usually 500 mg] IV every eight hours).

 

For brain abscesses with an unknown source, we recommend treatment with:

Vancomycin (15 to 20 mg/kg per dose IV every 8 to 12 hours, not to exceed 2 g per dose) PLUS

 

●Either ceftriaxone (2 g IV every 12 hours) or cefotaxime (2 g IV every four to six hours) PLUS

 

Metronidazole (15 mg/kg [usually 1 g] IV as a loading dose, followed by 7.5 mg/kg [usually 500 mg] IV every eight hours)

 

 

硬膜下膿瘍

 

SUMMARY AND RECOMMENDATIONS

 

●Epidural abscess is a rare but important suppurative infection of the central nervous system (CNS). Abscesses that are enclosed within the bony confines of the skull or spinal column can expand to compress the brain or spinal cord and cause severe symptoms, permanent complications, or even death. Prompt diagnosis and proper treatment can avert complications and achieve cure in many cases. 

 

●Intracranial epidural abscesses (IEAs) are less common than spinal epidural abscesses (SEAs) and less acute in their evolution. Organisms usually spread into the potential extradural space by direct extension from a contiguous focus of infection or by inoculation during trauma or neurosurgery. In the past, most cases were associated with sinusitis, otitis, or mastoiditis. Today, many cases arise as a complication of neurosurgical procedures. 

 

●If the inciting infection arises from the paranasal sinuses or ears, the organisms are likely to be microaerophilic or anaerobic streptococci and/or other anaerobes such as Cutibacterium (formerly Propionibacterium) and Peptostreptococcus species. If infection follows neurosurgery, the most likely organisms are staphylococci, especially Staphylococcus aureus, and gram-negative bacteria. 

 

●Signs and symptoms develop both as a result of infection and the slowly expanding intracranial mass. The latter can eventually cause raised intracranial pressure, papilledema, and, in some cases, focal neurologic signs. Fever, headache, lethargy, nausea, and vomiting are common.

 

●The key to diagnosis is to consider this rare condition then to perform a physical examination followed by appropriate imaging. Magnetic resonance imaging (MRI)  usually provides more information than computed tomography.

 

●Successful treatment of an IEA usually requires a combination of a drainage procedure and antibiotic therapy. Neurosurgical drainage is most commonly performed via burr holes or a craniotomy. 

 

●The decision of when to start antimicrobial therapy should be made on a case-by-case basis, depending upon the clinical circumstances. In immunocompetent patients who are not severely ill (ie, do not have neurologic deficits and are not septic) and for whom a surgical procedure to drain the abscess is planned over the following one to two days, it is reasonable to delay antimicrobial therapy until a specimen of the abscess fluid can be obtained. In such patients, an empiric regimen should be started as soon as a specimen has been collected. In immunocompromised patients, patients who have concerning clinical findings, and patients for whom surgery cannot be performed within one to two days, empiric therapy should be started without waiting for a specimen. 

 

●Empiric antibiotic therapy should be chosen based upon the probable origin of the infection and the likely causative organisms. For example, if contiguous infection of the paranasal sinuses, ear, or mastoid is the source, a regimen that is active against streptococci, Haemophilus species, and anaerobes should be chosen. An appropriate parenteral regimen for adults with contiguous infection is metronidazole plus either ceftriaxone orcefotaxime. In most other instances, an empiric regimen with antibiotics active against staphylococci, streptococci, and gram-negative bacilli should be chosen. An appropriate parenteral regimen is vancomycin plus metronidazole plus either cefotaxime or ceftriaxone or ceftazidime; ceftazidime should be the cephalosporin selected if Pseudomonas aeruginosa is a possible or likely pathogen.

 

●When the etiologic agent or agents have been identified by culture, treatment regimens should be simplified and directed to that pathogen or those pathogens.

 

●The appropriate duration of antimicrobial therapy should be determined on a case-by-case basis, taking into account the clinical, laboratory (white blood cell count, erythrocyte sedimentation rate, C-reactive protein), and radiographic response to therapy. The usual duration of therapy is six to eight weeks. The first follow-up MRI is obtained at about four to six weeks if the patient is improving or at any time if clinical deterioration occurs. 

 

 

ポイント・感想

 

  • 中枢神経系へ移行しやすい抗菌薬を選択する。
  • 4から8週間は抗菌薬投与する。
  • エンピリックは、背景によって異なる。
  • 副鼻腔炎由来であれば、MNZ + CTRX or CTX or PCG 2400。
  • 痙攣あると、MEPMは躊躇してしまうのが、複雑な背景があれば選択もありだろう。ただし、2g x 3回の超高用量。
  • CFPMは、CFPM脳症が話題なので消極的。

 

本症例は、CT上にて副鼻腔炎由来が考えられるが、コミュニケーションがもともと取りづらく不明な点が多い背景があり、さらに重症度は非常に高かったため、

培養確定するまで、VCM + CTX + MNZ or VCM + MEPM を推奨。

培養確定後、連鎖球菌 ± 嫌気菌 であれば、 PCG 2400万 + MNZ へDe-escalation。

 

 

 

本日のドライブ選曲

 

 

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