December 30, 2024

38-year-old man with a history of alcohol abuse presents to you with symptoms of sinusitis

By Med-Challenger · 2 minute read

A 38-year-old man with a history of alcohol abuse presents to you with nasal stuffiness, productive cough, high fever, and purulent nasal discharge for the last month. Two weeks ago, he presented to the emergency department and was given a prescription for amoxicillin/clavulanate, but pharmacy records reveal he did not fill it. Today he is brought to you by a friend after a witnessed tonic–clonic seizure.

On examination, the patient is stuporous and febrile. A full neurologic examination is difficult to perform; however, the patient opens his eyes and seems to be able to move his 4 extremities. Computed tomography of the head is shown below (see figure).

image (51)

Figure.

What is the most appropriate empiric treatment for this patient?

metronidazole and ceftriaxone
linezolid and cefepime
ceftriaxone and vancomycin
ceftaroline
penicillin and gentamicin

The correct answer is:

metronidazole and ceftriaxone

Educational Objective:

Treat brain abscess.

Key Point:

Select empiric antibiotics for a patient with brain abscess based upon presumptive source of infection. Surgical drainage is often required.

Explanation:

The patient has a brain abscess originating from a focus of sinusitis. Common organisms involved in this condition include species of Streptococcus, Haemophilus, and anaerobes. The best antibiotic coverage in this case will include ceftriaxone and metronidazole. Aspiration of the abscess and surgical evaluation are also a consideration. Corticosteroids could be used in the presence of mass effect.

The choice of antibiotics for a brain abscess depends on the subjacent conditions. For infections with presumptive initial foci in the mouth, ear, or sinuses, combination ceftriaxone/metronidazole is reasonable. If a hematogenous source is likely (eg, endocarditis), or occurs in the presence of penetrating trauma, then vancomycin should be added to cover for methicillin-resistant Staphylococcus aureus. Postneurosurgical cases may benefit from coverage for methicillin-resistant Staphylococcus aureus and for Pseudomonas.

Certain antibiotics, such as aminoglycoside, do not penetrate well into the central nervous system and are not recommended.

References:

Arlotti M, Grossi P, Pea F, Tomei G, Vullo V, et al; GISIG Working Group on Brain Abscesses. Consensus document on controversial issues for the treatment of infections of the central nervous system: bacterial brain abscesses. Int J Infect Dis. 2010;14(suppl 4):S79-S92.

Helweg-Larsen J, Astradsson A, Richhall H, Erdal J, Laursen A, Brennum J. Pyogenic brain abscess, a 15 year survey. BMC Infect Dis. 2012;12:332.

Gaillard, Frank. “Brain Abscess.” Radiopaedia.org.

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