Feasibility of early switch to oral antibiotic in brain abscesses and empyema: a multicentre retrospective study

Safe early switch to oral antibiotics in immunocompetent adults with intracranial bacterial suppurations: Retrospective of a 25-year experience in a tertiary care centre

BACKGROUND

Switching antibiotic therapy from intravenous to oral route (IVOS) has become the standard of care for many deep-seated infections. IVOS seems applicable to intracranial bacterial suppurations (ICBS) with a good safety profile but remains debated and has shown insufficient evidence to be recommended in the latest guidelines. We hypothesize that early IVOS is not associated with a poorer neurological prognosis.

MATERIAL

We conducted a single-center retrospective cohort study in a French tertiary hospital between October 1998 and June 2022. We included adult patients neuro-surgically treated for ICBS, who survived early hospitalization. The primary endpoint was to determine if outcome was associated with the duration of intravenous antibiotic therapy prior to IVOS. Secondary endpoints were total duration of antibiotic treatment, adverse effects and safety parameters.

RESULTS

We analysed data for 190 patients of whom 91 % underwent IVOS, after a median 9 days (IQR 5-15) of intravenous route. Patients with a favourable 6-month outcome (Glasgow Outcome Scale Extended ≥ 7) were more likely to receive shorter intravenous treatment (8 (IQR 5-15) versus 13 (IQR 5-23) days, p = 0.035). Patients having undergone early IVOS had fewer surgical revisions (p = 0.002). Treatment side effects did not differ between groups.

CONCLUSION

In patients with intracranial bacterial suppurations who have undergone surgery and are adequately monitored, switching from intravenous to oral antibiotics was not associated with a worse outcome, even when performed early. The absence of association between IVOS and death or poorer outcome requires confirmation in further studies.

Update and approach to patients with brain abscess

PURPOSE OF REVIEW

The epidemiology of brain abscess has changed in recent decades. Moreover, acute and long-term management remains challenging with high risks of mortality and neurological sequelae. This review describes recent advances in epidemiology, diagnosis, and treatment of brain abscess.

RECENT FINDINGS

The incidence of brain abscess is increasing, especially among elderly individuals. Important predisposing conditions include dental and ear-nose-throat infections, immuno-compromise, and previous neurosurgery. Molecular-based diagnostics have improved our understanding of the involved microorganisms and oral cavity bacteria including anaerobes are the predominant pathogens. The diagnosis relies upon a combination of magnetic resonance imaging, neurosurgical aspiration or excision, and careful microbiological examinations. Local source control by aspiration or excision of brain abscess combined with long-term antimicrobials are cornerstones of treatment. Long-term management remains important and should address neurological deficits including epilepsy, timely diagnosis and management of comorbidities, and potential affective disorders.

SUMMARY

A multidisciplinary approach to acute and long-term management of brain abscess remains crucial and source control of brain abscess by neurosurgery should be pursued whenever possible. Numerous aspects regarding diagnosis and treatment need clarification. Nonetheless, our understanding of this complicated infection is rapidly evolving.

European society of Clinical Microbiology and Infectious Diseases guidelines on diagnosis and treatment of brain abscess in children and adults

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 I2 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.

Early switch to oral antimicrobials in brain abscess: a narrative review

BACKGROUND

Early switch to oral antimicrobials has been suggested as a treatment strategy in patients with brain abscess, but the practice is controversial.

OBJECTIVES

This review aimed to summarize the background, current evidence, and future perspectives for early transition to oral antimicrobials in patients with brain abscess.

SOURCES

The review was based upon a previous systematic review carried out during the development of the ESCMID guidelines on diagnosis and treatment of brain abscess. The search used 'brain abscess' or 'cerebral abscess' as text or MESH terms in PubMed, EMBASE, and the Cochrane Library. Studies included in the review were required to be published in the English language within the last 25 years and to have a study population of ≥10 patients. Other studies known by the authors were also included.

CONTENT

In this review, the background for some experts to suggest early transition to oral antimicrobials in patients with mild and uncomplicated brain abscess was clarified. Next, results from observational studies were summarized and limitations discussed. Indirect support for early oral treatment of brain abscess was described with reference to other serious central nervous system infections and general pharmacological considerations. Finally, variations within and between countries in the use of early transition to oral antimicrobials in patients with brain abscess were highlighted.

IMPLICATIONS

Early transition to oral antimicrobials in patients with uncomplicated brain abscess may be of benefit for patients due to convenience of treatment and potential decreased risks associated with prolonged hospitalization and intravenous lines. The strategy may also confer a more rational allocation of healthcare resources and decrease expenses. However, the benefit/risk ratio for this strategy remains unresolved at present.