The cornerstone of early ED treatment of brain abscess is antibiosis. The susceptibility of the likely pathogen and the penetration of the agent into the lesion should be considered when choosing an antibiotic. The bacteriologic characteristics of the lesion may be inferred if the origin is obvious. Initial empiric antibiotic choice should take advantage of such information. Initial treatment in a suspected otogenic case is with a third-generation cephalosporin, such as cefotaxime, or trimethoprim-sulfamethoxazole with metronidazole or chloramphenicol. For presumed abscess of sinogenic or odontogenic origin, high-dose penicillin is a good choice. Penicillin is also appropriate for an abscess of hematogenous origin. Chloramphenicol or metronidazole, which by virtue of their lipophilic nature penetrate abscesses very well, is usually added to these penicillin regimes. When communication with the exterior is suspected, as in penetrating trauma or after neurosurgery, nafcillin or vancomycin are indicated. Addition of ceftazidime may be required if gram-negative aerobes are suspected. For patients in whom no mechanism is apparent or suspected, the combination of a third-generation cephalosporin, such as cefotaxime, and metronidazole provides good coverage.

Most cases require neurosurgery for diagnosis and bacteriologic analysis, if not for definitive treatment. Total excision has become necessary less often with the availability of imaging techniques for following the course of abscesses treated medically after surgical aspiration. In cases in which intracranial pressure is high, excision is still carried out. The role of glucocorticoids is controversial. Steroids may produce temporary improvement of increased intracranial pressure. 1 l8

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