Clinical and Microbiologic Features Guiding Treatment Recommendations for Brain Abscesses in Children

TY - JOUR

T1 - Clinical and Microbiologic Features Guiding Treatment Recommendations for Brain Abscesses in Children

AU - Felsenstein, Susanna

AU - Williams, Bhanu

AU - Shingadia, Delane

AU - Coxon, Lucy

AU - Riordan, Andrew

AU - Demetriades, Andreas K.

AU - Chandler, Chris

AU - Bassi, Sanj

AU - Koutoumanou, Eirini

AU - Stapleton, Simon

AU - Sharland, Mike

AU - Bryant, Penelope A.

PY - 2013/2

Y1 - 2013/2

N2 - Background: There are no guidelines for the management of brain abscesses in children, and there is a paucity of recent data describing clinical and microbiologic features. We aimed to identify factors affecting outcome to inform antibiotic recommendations.Methods: From 1999 to 2009, 118 children presented with brain abscesses to 4 neurosurgical centers in the United Kingdom. Clinical, microbiologic and treatment data were collected.Results: The commonest preceding infection was sinusitis, with 59% of all children receiving antibiotics before diagnosis. Nonspecific symptoms were common, with only 13% having the triad of fever, headache and focal neurological deficit. Time between symptom onset and diagnosis varied widely (median, 10 days; range, 0-44). Magnetic resonance imaging was more frequently diagnostic than computed tomography. The most frequent organisms were Streptococcus milleri (38%), except after penetrating head injury or neurosurgery, for which Staphylococcus aureus was most common. The commonest empiric antibiotics were ceftriaxone/cefotaxime and metronidazole, which offered effective antimicrobial therapy in up to 83% of cases. Metronidazole added benefit in a maximum of 7% of cases, with ceftriaxone/cefotaxime alone sufficient in at least 76% and in all cases with cyanotic congenital heart disease or meningitis. A carbapenem would have been effective in 90%. The case fatality rate was 6% (33% in the immunocompromised). Long-term neurological sequelae affected 35%. Age younger than 5 years and a Glasgow Coma Scale score Conclusions: We recommend ceftriaxone/cefotaxime and metronidazole as empiric treatment, although metronidazole may be unnecessary in many cases, with antistaphylococcal cover in cases of head trauma. Meropenem potentially would be a better choice in the immunocompromised. A prospective study of intravenous and oral treatment guided by clinical improvement is required beause 1-2 weeks of intravenous antibiotics during a total of 6 weeks may be sufficient in children.

AB - Background: There are no guidelines for the management of brain abscesses in children, and there is a paucity of recent data describing clinical and microbiologic features. We aimed to identify factors affecting outcome to inform antibiotic recommendations.Methods: From 1999 to 2009, 118 children presented with brain abscesses to 4 neurosurgical centers in the United Kingdom. Clinical, microbiologic and treatment data were collected.Results: The commonest preceding infection was sinusitis, with 59% of all children receiving antibiotics before diagnosis. Nonspecific symptoms were common, with only 13% having the triad of fever, headache and focal neurological deficit. Time between symptom onset and diagnosis varied widely (median, 10 days; range, 0-44). Magnetic resonance imaging was more frequently diagnostic than computed tomography. The most frequent organisms were Streptococcus milleri (38%), except after penetrating head injury or neurosurgery, for which Staphylococcus aureus was most common. The commonest empiric antibiotics were ceftriaxone/cefotaxime and metronidazole, which offered effective antimicrobial therapy in up to 83% of cases. Metronidazole added benefit in a maximum of 7% of cases, with ceftriaxone/cefotaxime alone sufficient in at least 76% and in all cases with cyanotic congenital heart disease or meningitis. A carbapenem would have been effective in 90%. The case fatality rate was 6% (33% in the immunocompromised). Long-term neurological sequelae affected 35%. Age younger than 5 years and a Glasgow Coma Scale score Conclusions: We recommend ceftriaxone/cefotaxime and metronidazole as empiric treatment, although metronidazole may be unnecessary in many cases, with antistaphylococcal cover in cases of head trauma. Meropenem potentially would be a better choice in the immunocompromised. A prospective study of intravenous and oral treatment guided by clinical improvement is required beause 1-2 weeks of intravenous antibiotics during a total of 6 weeks may be sufficient in children.

KW - microbiology

KW - antibiotics

KW - brain abscess

KW - MANAGEMENT

KW - THERAPY

U2 - 10.1097/INF.0b013e3182748d6e

DO - 10.1097/INF.0b013e3182748d6e

M3 - Article

SN - 0891-3668

VL - 32

SP - 129

EP - 135

JO - Pediatric Infectious Disease Journal

JF - Pediatric Infectious Disease Journal

IS - 2

ER -