Clin. microbiol. infect; 30 (1), 2024
Publication year: 2024
These European Society of Clinical Microbiology and Infectious Diseases guidelines are intended
for clinicians involved in diagnosis and treatment of brain abscess in children and adults.
Methods:
Key questions were developed, and a systematic review was carried out of all studies published
since 1 January 1996, using the search terms ‘brain abscess’ OR ‘cerebral abscess’ as Mesh terms or text in
electronic databases of PubMed, Embase, and the Cochrane registry. The search was updated on 29 September
2022. Exclusion criteria were a sample size <10 patients or publication in non-English language. Extracted
data was summarized as narrative reviews and tables. Meta-analysis was carried out using a random effects
model and heterogeneity was examined by I
2 tests as well as funnel and Galbraith plots. Risk of bias was
assessed using Risk Of Bias in Non-randomised Studies - of Interventions (ROBINS-I) (observational studies)
and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) (diagnostic studies). The Grading of Recommendations Assessment, Development and Evaluation approach was applied to classify strength of
recommendations (strong or conditional) and quality of evidence (high, moderate, low, or very low).
Questions addressed by the guidelines and recommendations:
Magnetic resonance imaging is recommended
for diagnosis of brain abscess (strong and high). Antimicrobials may be withheld until aspiration or excision
of brain abscess in patients without severe disease if neurosurgery can be carried out within reasonable time,
preferably within 24 hours (conditional and low). Molecular-based diagnostics are recommended, if available, in patients with negative cultures (conditional and moderate). Aspiration or excision of brain abscess is
recommended whenever feasible, except for cases with toxoplasmosis (strong and low). Recommended
empirical antimicrobial treatment for community-acquired brain abscess in immuno-competent individuals
is a 3rd-generation cephalosporin and metronidazole (strong and moderate) with the addition of
trimethoprim-sulfamethoxazole and voriconazole in patients with severe immuno-compromise (conditional and low). Recommended empirical treatment of post-neurosurgical brain abscess is a carbapenem
combined with vancomycin or linezolid (conditional and low). The recommended duration of antimicrobial
treatment is 6e8 weeks (conditional and low). No recommendation is offered for early transition to oral
antimicrobials because of a lack of data, and oral consolidation treatment after 6 weeks of intravenous
antimicrobials is not routinely recommended (conditional and very low). Adjunctive glucocorticoid treatment is recommended for treatment of severe symptoms because of perifocal oedema or impending herniation (strong and low). Primary prophylaxis with antiepileptics is not recommended (conditional and very
low). R