Brain abscess arising in a patient with severe immunocompromise — whether due to solid organ transplantation, active chemotherapy or biological treatment, or an underlying haematological malignancy — requires a management approach specifically adapted to this high-risk population.
Severe immunocompromise markedly expands the range of possible causative organisms and demands broader empirical cover from the outset. This protocol applies to patients meeting criteria equivalent to one of the following conditions:
Early neurosurgical intervention — aspiration or excision of the abscess — is a central component of management whenever feasible. This is combined with empirical intravenous antimicrobial cover that is substantially broader than in immunocompetent patients, targeting the wider pathogen spectrum seen in this population. The complete regimen, alternative options, duration, and indications for adjunctive therapy are set out in the full structured protocol.
Resolution of fever within 10–14 days and reduction of brain abscess volume on brain imaging by 4 weeks after aspiration.
DOI: 10.1016/j.cmi.2023.08.016
We strongly recommend neurosurgical aspiration or excision of brain abscess as soon as possible in all patients whenever feasible (excl. toxoplasmosis) (strong recommendation, moderate certainty of evidence).
We conditionally recommend a 3rd-generation cephalosporin and metronidazole combined with trimethoprim-sulfamethoxazole and voriconazole for empirical treatment of brain abscess in children and adults with severe immuno-compromise equivalent to organ transplant recipients, active chemotherapy or biological treatment, or haematological malignancies (Table 4) (conditional recommendation and very low certainty of evidence).
Another study used absence of fever for 10–14 days combined with resolution of abscess on brain imaging to guide treatment in 55 neurosurgically treated patients.
Although the radiological evolution of brain abscess varies considerably, abscess volume is often stationary or only slightly diminished on brain imaging by 2 weeks after aspiration, whereas lack of regression by 4 weeks is unusual.
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