Subdural empyema medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]; Anthony Gallo, B.S. [3]

Subdural empyema is a medical emergency and requires prompt treatment. Treatment of subdural empyema requires a combined medical and surgical approach. Empiric antimicrobial therapy depends on the location of the infection (intracranial vs. spinal) and whether it was community-acquired or hospital-acquired. The preferred regimen for intracranial subdural empyema includes (vancomycin 30–45 mg/kg/day IV q8–12h for 3-4 weeks OR nafcillin 2 g IV q4h for 3-4 weeks OR oxacillin 2 g IV q4h for 3-4 weeks) AND (ceftriaxone 2 g IV q12h for 3-4 weeks OR cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND metronidazole 7.5 mg/kg IV q6h for 3-4 weeks. The preferred regimen for spinal subdural empyema includes (vancomycin 30–45 mg/kg/day IV q8–12h for 3-4 weeks OR nafcillin 2 g IV q4h for 3-4 weeks OR oxacillin 2 g IV q4h for 3-4 weeks). Duration of therapy is usually 3-4 weeks, but more prolonged therapy (total of 6-8 weeks) may be necessary among patients who develop complications of the disease, such as osteomyelitis.

The treatment of intracranial or spinal subdural empyema requires both prompt surgical drainage and appropriate antibiotic therapy.^[1] Some patients may also present with seizures as a complication to subdural empyema, either during the acute phase or up to 2 years following. In these patients, therapy with phenytoin may be needed. Depending on the severity of the disease and the degree of neurological sequelae, physical and speech therapy may also be recommended.^[2]

• Subdural empyema^[3][4]

• Empiric antimicrobial therapy

• Metronidazole is recommended if anaerobes are suspected. Metronidazole is not necessary for antianaerobic activity if Meropenem is used.
• For coverage of aerobic Gram-negative bacilli, empiric therapy with Cefepime, Ceftazidime, or Meropenem is appropriate.
• Depending on the clinical response, parenteral antimicrobial therapy should be administered for 3 to 4 weeks after drainage. Parenteral or oral therapy is frequently continued for up to a total of 6 weeks of therapy.
• A longer course of treatment (minimum of 6–8 weeks) may be required if the patient has accompanying osteomyelitis.
• Consider adjunctive medications including prophylactic anticonvulsants, corticosteroids, and mannitol if clinically indicated.

• Intracranial subdural empyema with unclear source of infection

• Preferred regimen: (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema associated with sinusitis or otitis media

• Preferred regimen: (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema after cranial trauma

• Preferred regimen: Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks
• Note: Vancomycin should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema after neurosurgical procedures

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 3-4 weeks AND Ceftazidime 2 g IV q8h for 3-4 weeks

• Intracranial subdural empyema in neonates (usually associated with meningitis)

• Infants < 1 month

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h for 3-4 weeks AND Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeks

• Infants 1–3 months

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h for 3-4 weeks AND (Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeks OR Ceftriaxone 100 mg/kg/day IV q12h for 3-4 weeks)

• Infants > 3 months

• Preferred regimen: Vancomycin 60 mg/kg/day IV q6h for 3-4 weeks AND (Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeksOR Ceftriaxone 100 mg/kg/day IV q12h for 3-4 weeks OR Cefepime 150 mg/kg/day IV q8h for 3-4 weeks)

• Spinal subdural empyema

• Preferred regimen: Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Pathogen-directed antimicrobial therapy

• Staphylococcus aureus, methicillin-resistant (MRSA)^[5]

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
• Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
• Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h OR Linezolid 10 mg/kg/dose PO/IV q8h
• Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin therapy.