In post-neurosurgical brain abscess, initial management does not always achieve adequate control. When specific response targets are not met, a clearly defined next step is warranted — and its indications differ from those of first-line intervention.
Post-neurosurgical brain abscess — an abscess arising as a complication of a neurosurgical procedure — where a first course of aspiration or excision combined with empirical intravenous antibiotics has been completed.
The preceding protocol consisted of neurosurgical aspiration or excision combined with empirical intravenous meropenem and vancomycin or linezolid (or alternative empirical regimens), with adjunctive dexamethasone considered for management of severe perifocal oedema.
Escalation to this next-line protocol is triggered when that initial approach fails to achieve its targets: resolution of fever within 10–14 days and reduction of brain abscess volume on brain imaging by 4 weeks after aspiration.
When the above targets are not met, this protocol defines the neurosurgical approach to take next. The intervention is procedural in nature — specific indications and selection criteria determine the form it takes. The full structured protocol contains the complete decision pathway.
DOI: 10.1016/j.cmi.2023.08.016
We conditionally recommend meropenem combined with vancomycin or linezolid for empirical treatment of post-neurosurgical brain abscess (Table 4) (conditional recommendation and very low certainty of evidence).
Repeated neurosurgical aspiration, or in selected cases excision, should be carried out in case of clinical deterioration or enlargement of brain abscess, and is almost always required in those without any reduction in brain abscess volume by 4 weeks after first aspiration (good clinical practice statement).
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