An update on bacterial brain abscess in immunocompetent patients

Management dilemmas in Nocardia brain infection

PURPOSE OF REVIEW

Brain nocardiosis is a rare but severe infection mostly occurring among immunocompromised patients. In this review, we present recent data on this infection and address some of the common clinical dilemmas encountered in patients with brain nocardiosis.

RECENT FINDINGS

Strategies used to approach a patient with suspected brain nocardiosis include the 'conservative strategy' (without early neurosurgery) and the 'neurosurgical strategy' (with early aspiration or excision of brain abscess[es]). The advantages and disadvantages of both strategies are summarised. Our opinion is that the use of the 'conservative strategy' should be limited to well-selected patients presenting with an easily accessible extra-neurological lesion(s) and have brain abscesses at low risk of treatment failure. In terms of antimicrobial therapy, we summarise the data supporting the use of a multidrug regimen in patients with brain nocardiosis.Last, we list possible reasons for treatment failure in patients with brain nocardiosis and suggest interventions to overcome them.

SUMMARY

Literature is scarce regarding brain nocardiosis, as a consequence of the rarity of this disease. A multidisciplinary and individualised management is required to optimise the outcome of patients with brain nocardiosis.

Lemierre's syndrome caused by Fusobacterium necrophorum complicated with multiple brain abscesses-A case report, literature review, and suggested management

We present an unusual case of Lemierre´s syndrome complicated by multiple brain abscesses, a literature review and suggested management. A young man with multiple brain abscesses deteriorated despite two weeks of directed antibiotics. A multidisciplinary approach was successful. Hyperbaric oxygen treatment (HBOT) should be considered in refractory or severe cases.

Subdural empyema in adult with recent SARS-CoV-2 positivity case report

Intracranial abscess, including subdural empyema, is a rare central nervous system infectious disease and diagnosis is often delayed due to patient presentation with non-specific neurologic findings. Here we report a 65-year-old male with a recent past medical history of SARS-CoV-2 infection who presented with three weeks of escalating headache in whom MRI imaging revealed a subdural empyema. He subsequently underwent two craniectomies, which resulted in eradication of the abscess and clinical improvement. This report highlights a potential link between SARS-CoV-2 infection and this patient's development of subdural empyema, which has not been documented elsewhere in the literature.

Diagnostics with clinical microbiome-based identification of microorganisms in patients with brain abscesses-a prospective cohort study

Brain abscesses are often polymicrobial and of unclear primary origin. Here, we compare the use of next-generation sequencing (NGS) technology with classical microbiological diagnostics for identification of clinically relevant microorganisms and describe the microbiome profiling with respect to the primary source of brain abscess. Thirty-six samples from 36 patients, with primary brain abscesses, were subjected to both culture- and 16S/18S rRNA Sanger sequencing-based diagnostics ("standard methods") and compared to a 16S/18S amplicon-based NGS, which were also subjected to a microbiome diversity analyses. Forty-seven species were identified with "standard methods" compared to 96 species with NGS, both confirming and adding to the number of species identified (p < 0.05). The variation of the brain abscess microbiome diversity was not continuous but could be stratified comparing the presumable origin of infection ("dental," "sinus," "disseminated," or "unknown"). Alpha diversity did not differ (p > 0.05) between groups while beta diversity differed significantly (p = 0.003) comparing disseminated vs the other presumable origin of infection. Interesting, clustering was also detected between "dental" and "sinusitis," although not significantly (p = 0.07). Microbiome-based diagnostics can increase sensitivity without losing specificity. The bacterial beta diversity differed between the presumably origin of the brain abscess and might help to clarify the primary source of infection.

Risk factors for unfavorable clinical outcomes in patients with brain abscess in South Korea

Background

Brain abscess can be life-threatening and manifest various neurological findings, although the mortality rate has decreased recently. We investigated the risk factors for unfavorable outcomes of patients with brain abscess.

Methods

A retrospective cohort study examined patients with brain abscess seen from May 2005 to December 2018 in a tertiary care hospital in Seoul, South Korea. We reviewed the medical records for clinical findings, therapeutic modalities, and prognostic factors of brain abscess. Unfavorable clinical outcomes were defined as death, moderate to severe disability with neurological deficits, or vegetative state at 1 year or at the time of discharge from outpatient follow-up.

Results

The study enrolled 135 patients: 65.2% were males; the mean age was 56 years. 35.6% had unfavorable outcomes. In multivariate analysis, higher Sequential Organ Failure Assessment (SOFA) (p < 0.001), pre-existing hemiplegia (p = 0.049), and higher Charlson comorbidity index (CCI) (p = 0.028) were independently associated with unfavorable outcomes.

Conclusions

Higher SOFA, pre-existing hemiplegia and higher Charlson comorbidity index were significant risk factors for unfavorable clinical outcomes in patients with brain abscess.

Viridans Group Streptococcus Meningitis in an Immunocompetent Child: A Case Report

Patient: Female, 14-month-old

Final Diagnosis: Viridans group streptococcus meningitis

Symptoms: Fever • irritability • vomiting

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

Neuroradiology of infectious diseases

PURPOSE OF REVIEW

Early diagnosis of central nervous system (CNS) infections is crucial given high morbidity and mortality. Neuroimaging in CNS infections is widely used to aid in the diagnosis, treatment and to assess the response to antibiotic and neurosurgical interventions.

RECENT FINDINGS

The Infectious Diseases Society of America (IDSA) guidelines have clear recommendations for obtaining a computerized tomography of the head (CTH) prior to lumbar puncture (LP) in suspected meningitis. In the absence of indications for imaging or in aseptic meningitis, cranial imaging is of low utility. In contrast, cranial imaging is of utmost importance in the setting of encephalitis, bacterial meningitis, ventriculitis, bacterial brain abscess, subdural empyema, epidural abscess, neurobrucellosis, neurocysticercosis, and CNS tuberculosis that can aid clinicians with the differential diagnosis, source of infection (e.g., otitis, sinusitis), assessing complications of meningitis (e.g., hydrocephalus, venous sinus thrombosis, strokes), need for neurosurgical interventions and to monitor for the response of therapy. Novel imaging techniques such as fast imaging employing steady-state acquisition (FIESTA), susceptibility-weighted imaging (SWI), and chemical exchange saturation transfer (CEST) contrast are briefly discussed.

SUMMARY

Though the radiological findings in CNS infections are vast, certain patterns along with clinical clues from history and examination often pave the way to early diagnosis. This review reiterates the importance of obtaining cranial imaging when necessary, and the various radiological presentations of commonly encountered CNS infections.

Management and Outcomes of Paediatric Intracranial Suppurations in Low- and Middle-Income Countries: A Scoping Review

Introduction: Intracranial suppurations account for a significant proportion of intracranial masses in low- and middle-income countries (LMICs), particularly among children. The development of better imaging equipment, antibiotics, and surgical techniques has enabled significant progress in detecting and treating intracranial abscesses. However, it is unclear whether these advances are accessible and utilised by LMICs. In this review, we aimed to describe the landscape of paediatric intracranial suppurations in LMICs. Methods: This scoping review was conducted using the Arksey and O'Malley framework. MEDLINE, EMBASE, WHO Global Index Medicus, AJOL and Google scholar were searched for relevant articles from database inception to January 18th, 2021. Publications in English and French were included. Results: Of the 1,011 records identified, 75 were included. The studies, on average, included 18.8 (95% CI = 8.4-29.1) children (mean age: 8.2 years). Most children were male (62.2%, 95% CI = 28.7-95.7%). Intracranial suppurations were most commonly (46.5%) located in the supratentorial brain parenchyma. The most prevalent causative mechanism was otitis (37.4%) with streptococcus species being the most common causative organism (19.4%). CT scan (71.2%) was most commonly used as a diagnostic tool and antibiotics were given to all patients. Symptoms resolved in 23.7% and improved in 15.3% of patients. The morbidity rate was 6.9%, 18.8% of patients were readmitted, and the mortality rate was 11.0%. Conclusion: Most intracranial suppurations were complications of preventable infections and despite MRI being the gold standard for detecting intracranial suppurations, CT scans were mostly used in LMICs. These differences are likely a consequence of inequities in healthcare and have resulted in a high mortality rate in LMICs.

Brain abscess due to listeria monocytogenes: A case report and literature review

RATIONALE

Listeria monocytogenes infective encephalitis is a rare phenomenon, which is more common in people with changed eating habits and immunodeficiency. To the best of our knowledge, listeria brain abscess is even more rare. In this case report, we summarized the clinical characteristics of listeria brain abscess, in order to explore the diagnosis and treatment of Listeria brain abscess, and raise awareness and attention to the disease.

PATIENT CONCERNS

A 64-years-old female patient presented to our institution with 4 days of right arm and leg weakness, the salient past history of the patient was nephrotic syndrome, membranous nephropathy diagnosed 6 months prior, for which she was prescribed glucocorticoids and cyclophosphamide.

DIAGNOSIS

Listeria monocytogenes was cultured in the blood of the patient. Comprehensive medical history and imaging features, she was diagnosed as listeria brain abscess.

INTERVENTIONS

The patient underwent ampicillin combined with meropenem but not surgery.

OUTCOMES

The patient recovered without complications. At a 3-month follow-up visit, the condition was better than that before treatment.

LESSONS

Listeria brain abscess is an unusual form of listeriosis, its clinical manifestations lack specificity. Early accurate diagnosis and standardized treatment can effectively promote the recovery of neurological function as well as reduce the morbidity and mortality and improve the prognosis.

Brain Abscess in the Current Decade (2010–2019) in India—A Review

Brain abscess outcomes have improved in recent years due to advancements in cranial imaging, microbiological techniques, minimally invasive neurosurgical procedures, and effective antibiotic treatments. However, the incidence of brain abscess remains unchanged in developing countries. We searched PubMed and Google Scholar for references using the key words “brain abscess” and “India” and reviewed both retrospective and prospective studies published in peer-reviewed journals in the current decade to understand the present status. The review shows that the patients’ ages, the predominance of male patients, the symptoms and locations of brain abscesses, and the types of bacteria associated with them have remained unchanged over the past decade. The most common predisposing condition in recent years has been chronic suppurative otitis media with a mortality rate of 7 to 10%. Middle ear infection is often neglected and not treated aggressively in Asian countries. It requires multidisciplinary treatment strategies to address the primary source of infection and better health awareness to prevent the development of brain abscess.

Encephalitis and Brain Abscess

PURPOSE OF REVIEW

This article reviews infections of the brain parenchyma and includes an overview of the epidemiology, pathogenesis, diagnostic approach, and management of infectious encephalitis and brain abscess.

RECENT FINDINGS

The epidemiology of infectious encephalitis and brain abscess has changed in recent years. Vaccination has reduced the incidence of certain viruses associated with encephalitis, while a decrease in fulminant otogenic infections has led to fewer brain abscesses associated with otitis media. However, changes in climate and human population density and distribution have enabled the emergence of newer pathogens and expanded the geographic range of others, and greater adoption of intensive immunosuppressive regimens for autoimmune conditions has increased the risk of opportunistic infections of the brain. The widespread use of early neuroimaging, along with improved diagnostic methodologies for pathogen detection, newer antimicrobial therapies with better brain penetration, and less invasive neurosurgical techniques, has resulted in better outcomes for patients with infectious encephalitis and brain abscess. Novel technologies including metagenomic next-generation sequencing are increasingly being applied to these conditions in an effort to improve diagnosis. Nevertheless, both infectious encephalitis and brain abscess continue to be associated with substantial mortality.

SUMMARY

Infectious encephalitis and brain abscess can present as neurologic emergencies and require rapid assessment, thorough and appropriate diagnostic testing, and early initiation of empiric therapies directed against infectious agents. Close clinical follow-up, proper interpretation of diagnostic results, and appropriate tailoring of therapeutic agents are essential to optimizing outcomes. Diagnosis and management of parenchymal brain infections are complex and often best achieved with a multidisciplinary care team involving neurologists, neurosurgeons, neuroradiologists, infectious disease physicians, and pathologists.

Osteosarcoma of the skull base presenting as a petrocavernous pseudoaneurysm and masquerading as an intracranial abscess: illustrative case

BACKGROUND

Telangiectatic osteosarcoma (TOS) is a rare and aggressive high-grade malignant neoplasm composed of blood-filled or empty cystic spaces resembling aneurysmal bone cysts. Uncommonly, TOSs can occur in the skull base.

OBSERVATIONS

The authors present a case of a TOS that presented as a petrocavernous carotid pseudoaneurysm and then masqueraded as an intracranial abscess. The prognosis for TOSs with intracranial involvement is typically unfavorable and inversely related to the degree of intracranial involvement.

LESSONS

Skull-based malignancies should be part of the differential diagnosis for a rapidly progressing lesion. Recovery of polymicrobial organisms during endoscopic sinus surgery should prompt reconsideration of the differential diagnosis. Postinflammatory changes from endovascular coiling have been described and can confound imaging and clinical findings.

Switch from parenteral to oral antibiotics for brain abscesses: a retrospective cohort study of 109 patients

OBJECTIVES

Brain abscess is one of the most serious diseases of the CNS and is associated with high morbidity and mortality. With regard to the lack of data supporting an optimal therapeutic strategy, this study aimed to explore the prognostic factors of brain abscess, putting emphasis on the impact of therapeutic decisions.

METHODS

We retrospectively included patients hospitalized for brain abscess during a period of 13 years. Comorbidities (Charlson scale), clinical presentation, microbiology culture, radiological features and therapeutic management were collected. Glasgow Outcome Scale (GOS) at 3 months and length of hospital stay were, respectively, the main and the secondary outcomes. Logistic regression was used to determine factors associated with outcome independently.

RESULTS

Initial Glasgow Coma Scale (GCS) ≤14 and comorbidities (Charlson scale ≥2) were associated with poor neurological outcome while oral antibiotic switch was associated with better neurological outcome. Oral switch did not appear to be associated with an unfavourable evolution in the subset of patients without initial neurological severity (GCS >14) on admission. Duration of IV regimen and time to oral switch were associated with the length of inpatient stay.

CONCLUSIONS

This study confirms the role of GCS and comorbidities as prognostic factors and presents reassuring data regarding the safety of oral switch for the antibiotic treatment of brain abscesses. Oral switch could prevent catheter-induced iatrogenic complications and allow a higher quality of life for patients.

Ventriculitis: A Severe Complication of Central Nervous System Infections

BACKGROUND

Ventriculitis, a dreaded complication of brain abscess, meningitis, and various neurosurgical procedures, has attracted limited attention in the medical literature.

METHODS

This is a retrospective, single-center study. We screened the medical files of all patients who had a brain imaging report that included the word "ventriculitis" during years 2005-2019. Only patients with clinical, microbiological, and imaging features of ventriculitis were included. Data were collected through a standardized questionnaire.

RESULTS

Ninety-eight patients fulfilled inclusion criteria: 42 women and 56 men, and the median age was 60 years (interquartile range, 48-68). The primary mechanism for ventriculitis was classified as follows: brain abscess (n = 29, 29.6%), meningitis (n = 27, 27.6%), intraventricular catheter-related (n = 17, 17.3%), post-neurosurgery (n = 13, 13.3%), and hematogenous (n = 12, 12.2%). The main neuroimaging features were intraventricular pus (n = 81, 82.7%), ependymal enhancement (n = 70, 71.4%), and intraventricular loculations (n = 15, 15.3%). The main pathogens were streptococci (n = 44, 44.9%), Gram-negative bacilli (n = 27, 27.6%), and staphylococci (n = 15, 15.3%). In-hospital and 1-year mortality rates were 30.6% (n = 30) and 38.8% (n = 38), respectively. Neurological sequelae were reported in 34 of 55 (61.8%) survivors, including cognitive impairment (n = 11), gait disturbances (n = 9), paresis (n = 7), behavior disorder (n = 6), and epilepsy (n = 5). On multivariate analysis, age >65 years, Glasgow Coma Scale score <13 at initial presentation, status epilepticus, hydrocephalus, and positive cerebrospinal fluid culture were associated with 1-year mortality. We built a scoring system to stratify patients with ventriculitis into low risk (12.5%), intermediate risk (36.5%), and high risk (71.4%) of death.

CONCLUSIONS

Ventriculitis is a severe complication of brain abscess, meningitis, or neurosurgery, with an in-hospital mortality rate of 30% and neurological sequelae in 60% of survivors.

Right hemiparesis caused by massive otogenic brain abscess in children: Unusual case report and review of the literature

Introduction

Hemiparesis caused by otogenic brain abscess in children is an unusual complication of Chronic Suppurative Otitis Media. Complications can occur when the disease is not treated properly so that the infection in the middle ear spreads intracranially.

Case presentation

We report a case of Chronic Suppurative Otitis Media with cholesteatoma in a 14-year-old boy with complications of right hemiparesis caused by an otogenic brain abscess. His management included open craniotomy, drainage of the abscess, radical mastoidectomy and intravenous antibiotics according to the result of the culture and sensitivity.

Clinical discussion

Commonly, the location of the abscess is closely related to the source of infection. Affected brain lobes usually depend on predisposing factors that cause the development of brain abscesses. In this case, clinical manifestations appear in the form of contralateral hemiparesis even though the source of infection comes from the ear. This can occur due to massive abscesses and the presence of extensive perifocal edema which results in pressure in the subcortex area. The patient underwent radical mastoidectomy in conjunction with an abscess excision craniotomy.

Conclusion

Hemiparesis caused by an otogenic brain abscess is unusual. Rapid and precise diagnosis and treatment can minimize patient mortality and morbidity.

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In the antibiotic era, right hemiparesis caused by otogenic brain abscess in children is uncommon.

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It is life-threatening if not treated properly.

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Hemiparesis occurs because of the massive abscess in the frontal and parietal lobe area.

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A collaboration between a neurosurgeon and an otologist to manage the disease was performed on the same occasion, showing good results.

Nocardia farcinica cerebral abscess: A systematic review of treatment strategies

PURPOSE

Nocardia farcinica is an opportunistic pathogen causing mainly pneumonia in immunocompromised patients, complicated in almost one-third of the cases by a thick-walled multiloculated cerebral abscess which induces significant morbidity and mortality. This review aims to assess the optimal treatment strategy for N. farcinica cerebral abscess.

METHODS

Report of a case. Medline database was used to conduct a systematic review from inception to January 2020 looking for English-language articles focused on N. farcinica cerebral abscess, in accordance with the PRISMA guidelines.

RESULTS

The research yielded 54 articles for a total of 58 patients. N. farcinica cerebral abscess displayed three different neuroimaging patterns: a single multiloculated abscess in half of the cases, multiple cerebral abscesses, or a small paraventricular abscess with meningitis. The patients who benefited from surgical excision of the abscess showed a trend towards a lower risk of surgical revision (8% versus 31%, P=0.06) and a lower mortality rate (8% versus 23%, P=0.18) than patients who benefited from needle aspiration. Twenty-two percent of the patients benefited from microbiological documentation from another site with a mortality rate of 23%.

CONCLUSION

Urgent multimodal MRI is necessary in face with clinical suspicion of cerebral nocardiosis. In case of single or multiple small cerebral abscesses, microbiological documentation can be obtained with puncture of pseudotumoral visceral lesions. In case of large or symptomatic cerebral abscess, an aggressive surgical excision seems a reliable option and can be preferred over needle aspiration. Long-term antibiotic therapy with cotrimoxazole is necessary thereafter.

MRI of Emergent Intracranial Infections and Their Complications

Acute intracranial infections of the central nervous system and skull base are uncommon but time sensitive diagnoses that may present to the emergency department. As symptoms are frequently nonspecific or lack typical features of an infectious process, a high index of suspicion is required to confidently make the diagnosis, and imaging may not only serve as the first clue to an intracranial infection, but is often necessary to completely characterize the disease process and exclude any confounding conditions. Although computed tomography is typically the initial imaging modality for many of these patients, magnetic resonance imaging offers greater sensitivity and specificity in diagnosing intracranial infections, characterizing the full extent of infection, and identifying potential complications. The aim of this article is to serve as a review of the typical and most important imaging manifestations of these infections that can be encountered in the emergent setting.

A rare case of polymicrobial brain abscess involving Actinomyces

Brain abscess is a focal intracranial infection that may present as a life-threatening emergency. Brain abscess can present with a wide range of clinical syndromes, and it results in high morbidity and mortality worldwide. Here we describe a rare case of the polymicrobial right parietal brain abscess, especially associated with Actinomyces in a 59-year-old male who presented with acute onset of left-sided weakness and altered mental status. The patient underwent surgical treatment (burrhole aspiration) and antibiotics with good improvement. Prompt diagnosis and treatment are critical for brain abscess and ultimately lead to better patient outcomes.

Case Report: Metagenomics Next-Generation Sequencing Can Help Define the Best Therapeutic Strategy for Brain Abscesses Caused by Oral Pathogens

Brain abscesses are associated with an increased long-term risk of new seizures and increased mortality within several years after infection. Common microorganisms that cause brain abscesses include bacteria, fungi, and mycoplasma. We report a 75-year-old man with a brain abscess caused by Prevotella denticola, an oral pathogen. Based on the clinical condition, we suspected that the patient had a blood-borne brain abscess, and he received antibiotics and systemic supportive treatment. The patient developed shock for the second time after negative Gram-staining results. Metagenomics next-generation sequencing showed one strain from the oral microbiome, confirming our hypothesis, and targeted antibiotic treatment was administered quickly. Thus, we report a case in which genomic analysis was the critical factor in determining the best antimicrobial therapy for administration.

How do I manage nocardiosis?

BACKGROUND

Nocardiosis is a rare infection that is often difficult to treat and may be life-threatening. There is no consensus on its management.

OBJECTIVES

Our aim was to provide the current evidence for the diagnosis and management of individuals with nocardiosis, and to propose a management approach for this uncommon infection.

SOURCES

We systematically searched the medical literature on nocardiosis for studies published between 2010 and 2020 and describing ten or more individuals.

CONTENT

Nocardiosis, a primarily opportunistic infection which may occur in immunocompetent persons, most commonly involves the lungs and frequently disseminates to other sites including the central nervous system. The reference standard for Nocardia species identification is molecular biology, and the preferred method for antibiotic susceptibility testing (AST) is broth microdilution. Monotherapy seems appropriate for patients with primary skin nocardiosis or non-severe pulmonary disease; we reserve a multidrug regimen for more severe infections. Species identification and AST results are often missing at initiation of antibiotics. Trimethoprim-sulfamethoxazole is the preferred agent for initial therapy, because Nocardia is very often susceptible to this agent, and because it has been the keystone of nocardiosis treatment for years. Linezolid, to which Nocardia is almost always susceptible, may be an alternative. When combination therapy is required, the repertoire of companion drugs includes third-generation cephalosporins, amikacin and imipenem. Therapeutic modifications should take into account clinical response to initial therapy and AST results. Treatment duration of 6 months is appropriate for most situations, but longer durations are preferred for disseminated nocardiosis and shorter durations are reasonable in low-risk situations. Secondary prophylaxis may be considered in selected individuals with permanent immunosuppression.

IMPLICATIONS

We hereby provide the clinician with an easy-to-use algorithm for the management of individuals with nocardiosis. We also illuminate gaps in evidence and suggest future research directions.

The Use of Adjunctive Steroids in Central Nervous Infections

Central nervous system (CNS) infections continue to be associated with significant neurological morbidity and mortality despite various existing therapies. Adjunctive steroid therapy has been employed clinically to reduce inflammation in the treatment of CNS infections across various causative pathogens. Steroid therapy can potentially improve clinical outcomes including reducing mortality rates, provide no significant benefit, or cause worsened outcomes, based on the causative agent of infection. The data on benefits or harms of adjunctive steroid therapy is not consistent in outcome or density through CNS infections, and varies based on the disease diagnosis and pathogen. We summarize the existing literature on the effects of adjunctive steroid therapy on outcome for a number of CNS infections, including bacterial meningitis, herpes simplex virus, West Nile virus, tuberculosis meningitis, cryptococcal meningitis, Angiostrongylus cantonensis, neurocysticercosis, autoimmune encephalitis, toxoplasmosis, and bacterial brain abscess. We describe that while steroid therapy is beneficial and supported in pathogens such as pneumococcal meningitis and tuberculosis, for other diseases, like Listeria monocytogenes and Cryptococcus neoformans they are associated with worse outcomes. We highlight areas of consistent and proven findings and those which need more evidence for supported beneficial clinical use of adjunctive steroid therapy.

Emergency Neuropharmacology

Management of acute neurologic disorders in the emergency department is multimodal and may require the use of medications to decrease morbidity and mortality secondary to neurologic injury. Clinicians should form an individualized treatment approach with regard to various patient specific factors. This review article focuses on the pharmacotherapy for common neurologic emergencies that present to the emergency department, including traumatic brain injury, central nervous system infections, status epilepticus, hypertensive emergencies, spinal cord injury, and neurogenic shock.

Treatment of community-acquired bacterial brain abscess: a survey among infectious diseases specialists in France, Sweden, Australia, and Denmark

To examine antimicrobial management of brain abscess and prioritize future trials. Self-administered, Internet-based survey of practices for treatment of community-acquired bacterial brain abscess among infectious diseases (ID) specialists in France, Sweden, Australia, and Denmark during November 2019. Respondents were also asked to rank future randomized controlled trials (RCTs) from 1 (high priority) to 6 (low priority). 310 ID specialists (45% female) from France (35%), Sweden (29%), Australia (25%), and Denmark (11%) participated in the survey, primarily from university hospitals (69%) with an on-site neurosurgical department (61%). Preferred empiric intravenous (IV) antimicrobials were cefotaxime (154/273, 56%) or ceftriaxone (68/273, 25%) combined with metronidazole for a median of 4 weeks (IQR 4-6), 4 weeks (IQR 2-4), and 6 weeks (IQR 4-6) for aspirated, excised, and conservatively treated patients, respectively. Early transition to oral antimicrobials (i.e., < 4 weeks of IV antimicrobials) was used by 134/269 (50%), whereas consolidation therapy with oral antimicrobials after a standard IV regimen (i.e., 4-8 weeks) was used by 123/264 (47%). Median prioritization scores for future RCTs were as follows: 1 (IQR 1-2) for an early transition to oral antimicrobials and duration of therapy, 3 (IQR 2-4) for comparisons of antimicrobial regimens, use of adjunctive dexamethasone, and neurosurgical aspiration versus excision, and 4 (IQR 3-5) for intracavitary antimicrobial instillation and drainage, and for prophylactic anti-epileptic therapy. Willingness to include patients into RCTs reflected prioritization scores. Duration of intravenous antimicrobial treatment and use of oral antimicrobials varies substantially among ID specialists. RCTs are needed to define optimal treatment of brain abscess.

An immunocompetent patient with culture-negative multiple brain abscesses caused by Fusobacterium nucleatum

The diagnosis and treatment of brain abscesses have advanced due to the utilization of modern microbiological and neurosurgical methods. Here we present a 49-year-old female patient presented with headache and neurological symptoms. Initial evaluation revealed multiple ring-enhanced brain lesions and a lung cavitary lesion initially suspected to represent a malignant process. Stereotactic aspiration provided the diagnosis of brain abscesses but yielded negative cultures. 16S ribosomal RNA analysis enabled the identification of Fusobacterium nucleatum. For ten weeks, the patient was treated with ceftriaxone and metronidazole. A marked clinical and radiological improvement was noted. Brain abscess is a severe intracranial infectious process with significant morbidity and mortality. Microbiological analysis is challenging due to the location of the infection, the broad spectrum of causative agents, and the low yield of cultures. Fusobacterium nucleatum is an anaerobic bacteria with a tendency to abscess formation and is isolated from 2% of brain abscesses. The utilization of 16S RNA analysis improves microbiological identification rates in brain abscesses, as in other infectious entities, enabling better pathogen characterization and more suitable treatment.

Facilitating heart transplantability in an end-stage heart failure patient with brain abscess and infected left ventricle assist device-A unique case report

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Therapeutic scope in a patient designated with no therapeutic option left.

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Strategy ineligible for heart transplantation for uncontrolled infection.

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Extraordinary case elucidating our unestablished treatment strategy.

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Finally after treatment patient was listed for heart transplantation.

Introduction

Heart transplantation is the desired therapy in end-stage heart failure (HF) and in patients with left-ventricular assist devices (LVAD) suffering from life-threatening complications on device. Comorbidities are frequent in end-stage HF and may refrain the patient from being listed for heart transplantation such as infections making surgery impossible.

Presentation of case

We report the first case of a patient with proven LVAD system infection who additionally suffers from a brain abscess that made listing for heart transplantation impossible, leaving this patient no apparent treatment option.

Conclusion

Our extraordinary treatment strategy finally resolved both the brain abscess and LVAD system infection through extensive conservative long-term treatment facilitating this patient to be finally listed for regular heart transplantation and sustained relieve of systemic infection.

Do brain abscesses have a higher incidence of odontogenic origin than previously thought?

OBJECTIVE

The aim of this study was to answer the following clinical question: "In patients admitted to a tertiary care hospital with a diagnosis of brain abscess, how common is odontogenic etiology?"

STUDY DESIGN

We designed a retrospective study of patients with brain abscesses diagnosed at the Massachusetts General Hospital between 1980 and 2017. Inclusion criteria were complete medical records outlining clinical course, relevant dental history, and radiographic and microbiologic data.

RESULTS

Of 167 intracranial abscesses, 88 (52.7%) originated from a head/neck source, and 12 (13.6%) were of odontogenic etiology. Dental radiographs in 7 cases showed active dental infection. The remaining 5 patients reported recent dental procedures. Frontal lobe localization was the most common (7 of 12 [58.3%]). Presenting signs included headache (66.7%), mental status changes (41.6%), visual deficits (41.6%), and speech difficulties (33.3%). Computed tomography (CT) or magnetic resonance imaging (MRI) confirmed all diagnoses. Drainage via open craniotomy was performed in 6 (50%) of 12 patients, and stereotactic CT-guided drainage in 4 (33.3%). The most common pathogens were Streptococcus milleri (45.5%), Staphylococcus species (27.3%), and Fusobacterium (27.3%). All cases had favorable outcomes. Five had residual neurologic deficits, 4 had persistent visual complaints, and a recurrent abscess developed in 1 case.

CONCLUSIONS

These findings showed a higher subset (13.6%) of brain abscesses that could be attributed to odontogenic etiology than previously reported in the literature and highlight the need to rule out dental sources in cryptogenic cases.

Overview of Brain-to-Gut Axis Exposed to Chronic CNS Bacterial Infection(s) and a Predictive Urinary Metabolic Profile of a Brain Infected by Mycobacterium tuberculosis

A new paradigm in neuroscience has recently emerged - the brain-gut axis (BGA). The contemporary focus in this paradigm has been gut → brain ("bottom-up"), in which the gut-microbiome, and its perturbations, affects one's psychological state-of-mind and behavior, and is pivotal in neurodegenerative disorders. The emerging brain → gut ("top-down") concept, the subject of this review, proposes that dysfunctional brain health can alter the gut-microbiome. Feedback of this alternative bidirectional highway subsequently aggravates the neurological pathology. This paradigm shift, however, focuses upon non-communicable neurological diseases (progressive neuroinflammation). What of infectious diseases, in which pathogenic bacteria penetrate the blood-brain barrier and interact with the brain, and what is this effect on the BGA in bacterial infection(s) that cause chronic neuroinflammation? Persistent immune activity in the CNS due to chronic neuroinflammation can lead to irreversible neurodegeneration and neuronal death. The properties of cerebrospinal fluid (CSF), such as immunological markers, are used to diagnose brain disorders. But what of metabolic markers for such purposes? If a BGA exists, then chronic CNS bacterial infection(s) should theoretically be reflected in the urine. The premise here is that chronic CNS bacterial infection(s) will affect the gut-microbiome and that perturbed metabolism in both the CNS and gut will release metabolites into the blood that are filtered (kidneys) and excreted in the urine. Here we assess the literature on the effects of chronic neuroinflammatory diseases on the gut-microbiome caused by bacterial infection(s) of the CNS, in the context of information attained via metabolomics-based studies of urine. Furthermore, we take a severe chronic neuroinflammatory infectious disease - tuberculous meningitis (TBM), caused by Mycobacterium tuberculosis, and examine three previously validated CSF immunological biomarkers - vascular endothelial growth factor, interferon-gamma and myeloperoxidase - in terms of the expected changes in normal brain metabolism. We then model the downstream metabolic effects expected, predicting pivotal altered metabolic pathways that would be reflected in the urinary profiles of TBM subjects. Our cascading metabolic model should be adjustable to account for other types of CNS bacterial infection(s) associated with chronic neuroinflammation, typically prevalent, and difficult to distinguish from TBM, in the resource-constrained settings of poor communities.

Molecular diagnosis of polymicrobial brain abscesses with 16S-rDNA-based next-generation sequencing

OBJECTIVES

Brain abscesses lead to high mortality despite antibiotic and surgical treatment. Identification of causative bacteria is important to guide antibiotic therapy, but culture-based methods and molecular diagnostics by Sanger sequencing of 16S PCR products are hampered by antibiotic treatment and the often polymicrobial nature of brain abscesses. We have applied 16S-rRNA-based next-generation sequencing (NGS) for metagenomic analysis of intracranial abscess (brain and epidural) and meningitis samples.

METHODS

Seventy-nine samples from 54 patients with intracranial abscesses or meningitis were included. DNA was subjected to 16S PCR. Amplicons were analysed with the Illumina MiSeq system, sequence reads were blasted versus the NCBI 16S bacterial database and analysed using MEGAN software. Results were compared to those of gram-staining, culture and Sanger sequencing.

RESULTS

The NGS workflow was successful for 51 intracranial abscesses (46 brain and five epidural) and nine meningitis samples. Inclusion of (mono)bacterial meningitis samples allowed us to establish a cut-off criterion for the exclusion of contaminating sequences. In total 86 bacterial taxa were identified in brain abscesses by NGS, with Streptococcus intermedius and Fusobacterium nucleatum as most prevalent species; Propionibacterium and Staphylococcus spp. were associated with epidural abscesses. NGS identified two or more bacterial taxa in 31/51 intracranial abscesses, revealing the polymicrobial nature of these infections and allowing the discrimination of up to 16 bacterial taxa per sample.

CONCLUSION

These results extend earlier studies showing that NGS methods expand the spectrum of bacteria detected in brain abscesses and demonstrate that the MiSeq platform is suitable for metagenomic diagnostics of this severe infection.

Brain abscesses and intracranial empyema due to dental pathogens: Case series

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Cerebral infection is rare but life-threatening disease.

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Dental origin for brain abscesses or intra cranial empyema is very rarely reported in the literature.

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Infected maxillary teeth are probably involved in contiguous spread of the infection to the brain.

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There is currently no guidelines in oral surgery to manage patients with cerebral infection from dental origin.

Introduction

Spontaneous brain abscess and intracranial empyema are rare but life-threatening diseases. They can result from potential complications of oral chronic infections. Given the similarity between most of the germs commonly found both in cerebral abscess and in oral cavity and its anatomic proximity, the oral cavity represents a major source of cerebral infections.

Presentation of cases

We report here a series of seven cases of intracranial abscesses and empyema due to dental pathogens that occurred in the neurosurgery department of our institute. Five of those seven cases were then cared in the oral surgery department of our institute.

Discussion

Bacteriological examination of the brain abscesses identified an oral commensal bacterium belonging to streptococci group in six patients (85.7%) and Porphyromonas Gingivalis, a pathogen oral germ involved in periodontal diseases in the seventh patient. For all patients examined, oral status and oral health were poor or moderate with the presence of dental caries, missing teeth and abundant dental plaque. Except the oral cavity, no other front door or infectious site were found.

Conclusion

This rare series of cases highlights the importance of systematically explore the oral cavity in presence of intracranial infection and to radically eradicate the potential infectious foci.

Microbial aetiology of brain abscess in a UK cohort: Prominent role of Streptococcus intermedius

BACKGROUND

Brain abscess is an uncommon condition, but carries high mortality. Current treatment guidelines are based on limited data. Surveillance of clinical, radiological and microbiology data is important to inform patient stratification, interventions, and antimicrobial stewardship.

METHODS

We undertook a retrospective, observational study of patients with brain abscess, based on hospital coding, in a UK tertiary referral teaching hospital. We reviewed imaging data, laboratory microbiology, and antibiotic prescriptions.

RESULTS

Over a 47 month period, we identified 47 adults with bacterial brain abscess (77% male, median age 47 years). Most of the abscesses were solitary frontal or parietal lesions. A microbiological diagnosis was secured in 39/47 (83%) of cases, among which the majority were of the Streptococcus milleri group (27/39; 69%), with a predominance of Streptococcus intermedius (19/27; 70%). Patients received a median of 6 weeks of intravenous antibiotics (most commonly ceftriaxone), with variable oral follow-on regimens. Ten patients (21%) died, up to 146 days after diagnosis. Mortality was significantly associated with increasing age, multiple abscesses, immunosuppression and the presence of an underlying cardiac anomaly.

CONCLUSION

Our data suggest that there has been a shift away from staphylococcal brain abscesses, towards S. intermedius as a dominant pathogen. In our setting, empiric current first line therapy with ceftriaxone remains appropriate on microbiological grounds and narrower spectrum therapy may sometimes be justified. Mortality of this condition remains high among patients with comorbidity. Prospective studies are required to inform optimum dose, route and duration of antimicrobial therapy.

[Otogenic and rhinogenic intracranial complications: meningitis and brain abscess in adults]

The purpose of this study is to review etiology, diagnosis and management strategies of rhinogenic and otogenic meningitis and brain abscess in adults. Current diagnostic procedures, effective surgery and antibiotic treatment are discussed. The clinical case of diagnosis and successful treatment of the patient with rhinogenic meningitis and brain abscesses is presented.

Clinical features, microbiology, and management of pediatric brainstem abscess

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.

Secondary encephalocele in an adult leading to subdural empyema

Brain abscesses are an uncommon but potentially fatal infection. They can spread directly from an adjacent source or hematogenously from a distant source. Encephaloceles represent a rare form of neural tube defects that can potentially be complicated by the development of meningitis or brain abscess. We report a case of a 63-year-old female who presented with bilateral lower extremity weakness and was ultimately found to have a Streptococcus pneumoniae subdural empyema and an associated frontal lobe encephalocele extending through the left frontal sinus. She was treated with surgical drainage, intravenous antimicrobials, and ultimately surgical repair of the encephalocele. This report highlights a unique presentation of brain abscess. Clinicians should be aware of this potential infectious complication of a neural tube defect.

Retrospective analysis of brain abscess in 183 patients: A 10-year survey

This study aims to identify predictive factors related to clinical outcome, reoperation, and complications in patients with brain abscess.Patients with a diagnosis of brain abscess at discharge at the Second Affiliated Hospital of Zhejiang University School of Medicine between 2008 and 2018 were reviewed. Logistic regression was used to identify predictive factors associated with Glasgow Outcome Scale (GOS) at discharge, GOS at 1 year after discharge, reoperation and complications.Among 183 patients enrolled into the study, 142 patients had a good outcome at discharge (GOS ≥ 4) and 41 had a poor outcome (GOS ≤ 3). During the follow-up period, 20 additional patients had a good outcome. A total of 156 patients were treated by open craniotomy excision (n = 72) and aspiration (n = 84), 10 of whom underwent reoperation. Complications in surgical patients for brain abscess occurred in 54 patients. Poor outcome was related to Glasgow coma scale (P = .007) and ventricular proximity (P = .001). Surgical method was associated with reoperation (P = .04) and complications (P < .001). Seizure at admission was related to epilepsy (P < .001). Surgical method was related to postoperative intracranial hemorrhage (P = .02).Glasgow coma scale (GCS) and ventricular proximity were associated with poor outcome. Further, patients who underwent aspiration were more likely to experience reoperation, while open craniotomy excision (OCE) was related to complications. Patients presenting seizure at admission were more likely to develop epilepsy. Patients who underwent OCE tended to experience postoperative intracranial hemorrhage.

A proposal for a tailored protocol for focal suppurative infection of the central nervous system: analysis of an institutional experience in pediatric patients

OBJECTIVE

The incidence of focal suppurative infections (FSIs) of the brain has significantly decreased owing to the better health and fundamental conditions of the population on the one hand and earlier detection and the availability of more potent antibiotics on the other. Interestingly, the antibiotic protocols have not been well defined in terms of duration despite a prompter diagnosis, definitive management of the etiology, and the advent of various higher-generation antibiotics. In this study, the authors evaluated the current treatment protocol. Their aim was to optimize management protocols for FSIs of the central nervous system based on clinical parameters.

METHODS

The study was a retrospective analysis of all children who had undergone surgical management for an FSI at the Division of Paediatric Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, in the period from January 2001 to February 2018. In addition to demographic characteristics, the details of culture reports and antibiotic regimens were collected. The response to treatment was compared to changes in the infective profile (C-reactive protein) and imaging. Instances of reaspiration were compared with clinical signs, imaging findings, and infective profiles. Treatment response was separated into two groups: responders within or at 2 weeks and responders beyond 2 weeks. The clinical characteristics of these two groups were compared.

RESULTS

Forty-eight children were treated in the study period. Nineteen patients benefited from the 2-week (short-term) protocol of intravenous antibiotics. Twenty-nine patients required more than 2 weeks (approximately 4 weeks; long-term protocol) for resolution. Of those requiring more than 2 weeks, 69% had cardiogenic etiology. All patients were followed up with a minimum of 3 weeks of oral antibiotics. In a comparative analysis between short-term and long-term responders, only etiology was significantly different. None of the patients who had the short-term protocol had a recurrence.

CONCLUSIONS

A shorter antibiotic protocol can be used successfully in carefully selected patients who are surgically treated and followed up. It is clear that the 2-week intravenous antibiotic protocol is more suitable for immunocompetent patients who have a noncardiogenic etiology.

Invasive Cryptococcal Meningitis Presenting as a Skull Base Mass in An Immunocompetent Host: A Case Report

Introduction  Encephalitis due to Cryptococcus neoformans has been seen almost exclusively in patients with severe compromise of their immune systems, such as acquired immune deficiency syndrome (AIDS). Fungal sinusitis with frank invasion through the cranial base and subsequent seeding of the central nervous system is rare, but should be considered in the differential of patients presenting with meningitis and sinus/skull base lesions even without obvious immune compromise. Improvements in diagnostic testing has increased the ability to correctly identify and new antimicrobials have allowed a condition that once carried a high morbidity and mortality to be managed with better outcomes. We present our treatment algorithm for successful management of an immunocompetent patient with extensive fungal encephalitis due to erosion through the skull base.

Case Description  The patient is a 59-year-old male presenting unresponsive with sphenoid mass erosive of the skull base and symptoms of meningitis and encephalitis due to C. neoformans . Magnetic resonance imaging (MRI) at presentation demonstrated extensive diencephalic invasion, and a sphenoid mass with erosion of the skull base. Lumbar puncture (LP) confirmed elevated opening pressure of 45 cm H2O, and cultures confirmed infection with C. neoformans . He underwent operative sinonasal debridement followed by placement of an external ventricular drain for management of hydrocephalus. He was treated aggressively with a combination of both intravenous (IV) amphotericin B daily and intrathecal amphotericin B via the ventriculostomy thrice weekly. By the 2nd week of treatment, patient regained consciousness. After 4 weeks of therapy, cerebrospinal fluid (CSF) cultures turned negative, and the external ventricular drain (EVD) was converted to a ventriculoperitoneal shunt (VPS) to manage chronic postinfectious hydrocephalus. We also placed a contralateral Ommaya reservoir to permit continued weekly intrathecal amphotericin B without violation of the shunt valve. With each instillation, the shunt was set to its highest setting to minimize CSF egress for 6 hours then reset to its “drainage” setting. After an additional 6 weeks of outpatient therapy, intrathecal therapy was discontinued. We continued CSF surveillance via Ommaya sampling monthly. At 9-month follow-up, he has remained clinically stable without evidence of recurrent infection. He has residual mild cognitive deficits, but is living semiindependently with his brother.

Conclusions  Fungal sinusitis is uncommon, especially in those without significantly compromised immune systems. Invasive fungal meningitis resulting in meningitis and encephalitis is even rarer. The condition carries high morbidity and mortality that can only be mitigated with a multidisciplinary effort by neurosurgery, otolaryngology, and infectious disease specialists. While there are no clear treatment guidelines, we present an approach that may permit longer term independent survival.

Predictors of reoperation and noninfectious complications following craniotomy for cerebral abscess

OBJECTIVES

There is a paucity of literature that examines predictors of reoperation and noninfectious complications following treatment of cerebral abscess with craniotomy. The goal of the present study is to identify predictors for each of these outcomes.

PATIENTS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database 2012-2016 file was the data source. Patients were identified using a combination of CPT and ICD-9/10 codes. Exclusions included missing age/gender, secondary surgery, and absent length of stay information. Univariate followed by multivariable analysis using logistic regression was used to identify significant predictors of reoperation and noninfectious postoperative complications (p < 0.05).

RESULTS

166 patients met the above criteria. Median age was 56 (IQR 44-65) and 68.1% of patients were men. The 30-day reoperation rate was 18.1% and increasing white blood cell count (WBC) was identified as a significant risk factor for reoperation (odds ratio [OR] 1.10, 95% CI 1.02-1.19, p = 0.013). Noninfectious complications occurred at a rate of 20.5% at 30 days. Significant predictors were ASA classification ≥4 (OR 4.13, 95% CI 1.74-9.81, p = 0.001), smoking (OR 3.04, 95% CI 1.18-7.78, p = 0.020), and increasing WBC count (OR 1.11, 95% CI 1.03-1.20, p = 0.007). Emergency case status, abscess location (supratentorial versus infratentorial), nor chronic steroid use demonstrated a significant relationship with the studied outcomes.

CONCLUSION

Increasing preoperative WBC count predicts both reoperation and noninfectious complications following craniotomy for cerebral abscess. Less modifiable predictors for noninfectious complications which may help anticipate operative risk are smoking and high ASA classification.

ESCMID white paper: a guide on ESCMID guidance documents

BACKGROUND AND AIM

The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) aims to further develop its role in international medical and scientific guidance in the field of Clinical Microbiology and Infectious Diseases, where many types of guidance documents exist. The ESCMID Executive Committee and the Clinical Microbiology and Infection (CMI) editorial board wish to clarify the terminology and format to be used in ESCMID guidance documents submitted for publication in CMI, and to highlight the principles behind ESCMID guidance documents.

TYPES OF GUIDANCE DOCUMENTS

There are five types of ESCMID guidance documents: White Papers, Clinical Practice Guidelines, Consensus Statements, State-of-the-Science Statements, and Position Papers. They differ in scope, methods of development, drafting group composition and preferred publication format. Guidance documents can be proposed, developed and published by ESCMID Study Groups, Committees and individual members; often, other scientific societies are involved. The full disclosure of potential conflicts of interest of all drafting group members is a requirement.

FINAL REMARKS

Guidance documents constitute a common cultural and scientific background to people in the same and related professions. Also, they are an important educational and training tool. Developing a guidance document is a scientific endeavour, where a sound and transparent development process is needed, requiring multidisciplinary and personal skills.

Pyogenic brain abscess and subdural empyema: presentation, management, and factors predicting outcome

PURPOSE

To describe the presentation and management of bacterial brain abscess and subdural empyema in adults treated at two tertiary centers. In addition, to identify factors that may predict a poor clinical outcome.

METHODS

A retrospective analysis of data obtained from clinical records was performed, followed by multivariate regression analysis of patient and treatment-related factors.

RESULTS

113 patients were included with a median age of 53 years and a male preponderance. At presentation symptoms were variable, 28% had a focal neurological deficit, and 39% had a reduced Glasgow coma scale (GCS). Brain abscesses most frequently affected the frontal, temporal, and parietal lobes while 36% had a subdural empyema. An underlying cause was identified in 76%; a contiguous ear or sinus infection (43%), recent surgery or trauma (18%) and haematogenous spread (15%). A microbiological diagnosis was confirmed in 86%, with streptococci, staphylococci, and anaerobes most frequently isolated. Treatment involved complex, prolonged antibiotic therapy (> 6 weeks in 84%) combined with neurosurgical drainage (91%) and source control surgery (34%). Mortality was 5% with 31% suffering long-term disability and 64% achieving a good clinical outcome. A reduced GCS, focal neurological deficit, and seizures at presentation were independently associated with an unfavorable clinical outcome (death or disability).

CONCLUSIONS

Complex surgical and antimicrobial treatment achieves a good outcome in the majority of patients with bacterial brain abscess and subdural empyema. Factors present at diagnosis can help to predict those likely to suffer adverse outcomes. Research to determine optimal surgical and antibiotic management would be valuable.

Multiple brain abscesses after professional tooth cleaning: Case report and literature review

Brain abscess (BA) is an encapsulated infection and can be the consequence of head and cranio-maxillo-facial surgery or trauma, or may be secondary to cavernous thrombophlebitis, but is most frequently due to hematogenous septic dissemination from an adjacent site of infection, such as the paranasal sinuses, middle ear or oral cavity. We report a rare and unfortunate case of multiple BA caused by dental procedures in a young man with undiagnosed patent foramen ovale (PFO). Simple routine dental procedures, such as tooth brushing and professional oral hygiene, can predispose to life-threatening conditions. This case report and literature review highlights that multiple BA after professional tooth cleaning is extremely rare, but cardiac defects (in first place PFO which is a potential source of paradoxical embolism) promote BA formation.