Treatment of Cerebral Abscess in Immunocompromised Patients

Antimicrobial Therapy

The American College of Physicians and Infectious Diseases Society of America recommend empirical antimicrobial therapy consisting of a 3rd-generation cephalosporin plus metronidazole, with the addition of trimethoprim-sulfamethoxazole and voriconazole to cover opportunistic pathogens including Nocardia, fungi, and Toxoplasma in severely immunocompromised patients 1, 2
The Infectious Diseases Society of America suggests that the combination of 3rd-generation cephalosporin and metronidazole covers oral cavity bacteria, anaerobes, and Enterobacteriaceae 4, 5
Trimethoprim-sulfamethoxazole is recommended to cover Nocardia spp., Toxoplasma gondii, and Listeria monocytogenes 1, 3
Voriconazole is recommended to cover Aspergillus, Candida, and other fungal pathogens including Scedosporium 1, 3

The American Association of Neurological Surgeons recommends neurosurgical intervention as soon as possible whenever feasible 2, 6
Abscesses ≥2.5 cm in diameter should undergo aspiration or excision to reduce mortality from 24% to 9% 6

The American College of Physicians recommends dexamethasone for severe symptoms due to perifocal edema or impending herniation 1, 2, 6
Primary prophylaxis with antiepileptic drugs is not recommended, but treat seizures if they occur 1, 2

The Infectious Diseases Society of America recommends performing brain MRI with diffusion-weighted imaging (DWI) and gadolinium-enhanced T1-weighted sequences every 2 weeks until clinical cure is evident 2, 6
Repeat aspiration or excision should be performed if clinical deterioration occurs, abscess enlarges on follow-up imaging, or no reduction in abscess volume by 4 weeks after initial aspiration 6, 7

Long-term neurological sequelae occur in approximately 45% of patients at 6 months, including focal deficits and neurocognitive impairment 6, 7
One-year mortality is substantially increased compared to matched controls, and rupture of cerebral abscess carries 27-50% mortality 6