Brain Abscess and Subdural Empyema in Neonates and Children - Guideline for management of
|Next review: 15/09/2025|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2022|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for Management of Brain Abscess and Subdural Empyema in Neonates and Children
A brain abscess is a focal, intra-cerebral infection, which usually begins as an area of cerebritis and develops into a collection of pus surrounded by a well-vascularised capsule. A brain abscess evolves through stages of early, late cerebritis followed by encapsulation. Intraventricular rupture of the brain abscess is associated with high mortality.
A subdural empyema is a collection of pus located inside the skull between the dura and arachnoid mater on the surface of the brain. It is usually unilateral and has a tendency to spread rapidly through the subdural space until limited by specific boundaries. Empyemas account for 20% of all intracranial abscess cases (Agrawal 2007). Empyemas also have an association with cerebral venous sinus thrombosis. At presentation the empyema is almost always the more life threatening pathology and needs to be managed first as an emergency to stabilise the patient but cerebral venous sinus thrombosis should be actively excluded once the patient is stable or as a differential in a deteriorating patient whose empyema has already been drained.
These infections are initiated when microorganisms are introduced into the brain tissue or subdural space following trauma; contiguous pericranial infection; meningitis or haematogenous dissemination from a distant infective focus. In the largest paediatric series (Tekkok 1992) infections involving middle ear, paranasal sinuses, penetrating trauma and congenital cyanotic heart disease were the most common predisposing factors. Haematogenous spread resulting from sepsis is less common.
There are no randomised controlled trials of therapy for children with brain abscess & empyema from which to draw recommendations. Available literature is largely retrospective, reviewing predisposing factors, microbiological features, treatment outcomes and prognostic indicators. Data on children is further limited as these series are based mainly on adults with a small number of children; subset data on children are not available in any of them. Hence the text that follows is based on current practice, expert recommendations and the limited literature.
Advances in neurosurgical techniques, newer antimicrobials and better imaging technologies have facilitated the diagnosis and management of intracranial pyogenic suppurations over past 20 years; however, they still remain potentially fatal central nervous system infections. Different factors had been described as influencing the outcome in studies including neurological status at admission, (intraventricular rupture of brain abscess) and multiple abscesses. Imaging severity based on number, location, extent of perilesional oedema and midline shift is also an important prognostic indicator (Demir MK 2007). Infancy is recognised as a risk factor for mortality (Tekkok 1992). Early recognition and management of predisposing conditions is important for improving the overall outcome.
Recommendation: CT head, ideally with contrast administration, is the imaging modality of choice.
CT with and without contrast is the first investigation used in almost all cases, however it may not be possible on CT to:
In these cases depending on the clinical picture and degree of radiological doubt a MRI with contrast and DWI (ideally + MRV given association with cerebral venous sinus thrombosis) is usually required if the patient is stable enough,
All patients with suspected abscess or subdural empyema on CT should however be urgently discussed with the neurosurgical team once suspicion is raised before/whilst arranging MRI as they are at risk of rapid deterioration.
Recommendation: MRI head may be required in some cases, following discussion with radiology.
* Abbreviations: CE = contrast enhancement
Recommendation: The treatment of brain abscesses should be a team approach, with collaboration between a Microbiologist, Neurologist, Neuroradiologist and Neurosurgeon.
Intracranial empyema drainage
Intraventricular rupture of abscess
Management of multiple brain abscess
|Empirical Antimicrobial Treatment|
Recommendation: Initial antimicrobial choice is empirical and should be tailored to cover the most likely pathogens in individual cases depending upon the location of the abscess/empyema and predisposing focus (dental, paranasal sinuses, otogenic etc.), according to Table 2.
* Use Ceftazidime as third generation cephalosporin if Pseudomonas infection suspected.
This would normally only be considered once imaging is showing an improving trend.
|Directed Antimicrobial Treatment (when microbiology results are known)|
Recommendation: Broad spectrum empirical antimicrobial regimens should be tailored to organism isolated from pus or blood cultures i.e. converted to “directed antimicrobial therapy” whenever possible (see Table 3).
**Dose adjusted according to estimated creatinine clearance; need to monitor Vancomycin trough levels.
|Duration of Treatment|
Recommendation: Duration of therapy should be determined by clinical progress, CT findings and whether surgical drainage has been undertaken.
Recommendation: Discussion between neurosurgery and microbiology is recommended.
|Clinical condition:||Brain abscess and subdural empyema in neonates and children|
|Target patient group:||Children and neonates with brain abscess and subdural empyema|
|Target professional group(s):||Secondary Care Doctors
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
- The rational use of antibiotics in the treatment of brain abscess REPORT BY THE `INFECTION IN NEUROSURGERY’ WORKING PARTY OF THE BRITISH SOCIETY FOR ANTIMICROBIAL CHEMOTHERAPY* British Journal of Neurosurgery 2000; 14(6): 525- 530
- Agrawal, A., Timothy, J,m Pandit, L., Shetty, L. & Shetty, J.P. A review of subdural empyema and its management, Infections Diseases in Clinical Practice. 2007 15(3).
- Brook I. Brain abscess in children: microbiology and management. J Child Neurol 1995 Jul; 10(4):283-8.
- Tekkök IH, Erbengi A. Management of brain abscess in children: review of 130 cases over a period of 21 years. Childs Nerv Syst. 1992 Oct; 8(7):411-6.
- Yogev R,Bar-Meir M. Management of brain abscesses in children.Pediatr Infect Dis J. 2004 Feb;23(2):157-9
- Demir MK, Hakan T, Kilicoglu G, Ceran N, Berkman MZ, Erdem I, Göktas P. Bacterial brain abscesses: prognostic value of an imaging severity index. Clin Radiol. 2007 Jun;62(6):564-72.
- Mathisen GE, Johnson JP. Brain Abscess. Clin Infect Dis. 1997; 25: 763-781
- Sheehan et al. Brain abscess in children. Neurosurg Focus.2008 Jun ;24:
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