Pediatric Neurology 50 (2014) e13ee14
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Letters to the Editor
Brain Abscess in a Newborn Eduardo Aran-Echabe, MD Department of Surgery University of Santiago de Compostela Santiago, Spain
To the Editor: We were interested to read the recent article by PérezBovet et al. (“Brain abscess as a cause of macrocephaly in a new born”)1 and would like to make a few comments based on our own experience with the same pathology.2 The authors state that: “Antibiotics were injected and drained. Empiric intravenous antibiotics were started.” It is important to know which antibiotics were administered in the abscess cavity. Second, we would like to know if the author’s hospital has an empirically based protocol for the antibiotic treatment of abscesses and subdural empyema. The empirical antibiotics should include coverage of anaerobic pathogens, such as a metronidazole, plus vancomycin if there is suspicion of Staphylococcus infection and cover against gram-negative pathogens (third-generation cephalosporin), especially in pediatric patients. This or a similar protocol can be administered until pus is drained and the antibiotic sensitivity reports become available; specific bactericidal agents for the organism cultured should be administered. We believe that this is important for the proper treatment of this pathology.2,3 Finally, we congratulate the authors on their result. We, as well as many authors, consider that, where possible, craniotomy with resection of the capsule is the best practice because it provides rapid improvement of neurological status, lower resurgery rates, shorter duration of postoperative antibiotic use, and shorter hospital stays. References 1. Pérez-Bovet J, da Silva-Freitas R, Puerta-Roldán P, GuillénQuesada A, Candela-Cantó S, García-Fructuoso G. Brain abscess as a cause of macrocephaly in a new born. Pediatr Neurol. 2014;50: 121-122. 2. Gelabert-González M, Serramito-Garcia R, García-Allut A, CutrinPrieto JM. Management of brain abscess in children. J Pediatr Child Health. 2008;44:731-735. 3. González-García J, Gelabert M, Pravos AG, Prieto A. Intracranial collections of pus. A review of 100 cases. Rev Neurol. 1999;29: 416-424.
Miguel Gelabert-González, PhD Neurosurgical Service Clinic Hospital of Santiago de Compostela Santiago, Spain E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pediatrneurol.2013.11.015
Brain Abscess as a Cause of Macrocephaly in a Newborn To the Editor: The authors thank Drs. Gelabert and Aran-Echabe for their interest in our report.1 We agree that empiric, broadspectrum antibiotics, followed by culture-directed therapy, is the mainstay of intracranial infection management. In answer to their question, our institution has a protocol to guide such management as we believe this constitutes standard practice. In patients with brain abscess, we use a combination of vancomycin, metronidazole, and ceftazidime, although other intracranial infections are treated with vancomycin and meropenem. Like Drs. Gelabert and Aran-Echabe, we considered that empiric therapy represents a broad-spectrum regimen, fully justified in most clinical settings. Regarding instillation of antibiotics into the abscess cavity, although no systematic approach has been studied in the literature (as far as we know), we empirically use gentamicin, again complying with institutional protocol. Finally, we agree that craniotomy is probably the surgical approach with the lowest recurrence rate, but we believe that certain clinical circumstances make less invasive approaches equally or more adequate. Discussion regarding different surgical options and optimal management is beyond the scope of our article. In the individual we described, our intention was to emphasize his particular clinical presentation, initially managed as an asymptomatic macrocephaly. Our aim was to illustrate an apparent disproportion between lesion size and alarming signs and between mass effect and neurological status. Obviously, the child was managed as an emergency as soon as he was referred to us. Neurosurgical intervention and intensive care surveillance were implemented immediately. The particular clinical setting of this patient gave us the
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Letters to the Editor / Pediatric Neurology 50 (2014) e13ee14
impression that craniostomy allowed immediate relief of mass effect with less risk of complications. The safe resection of the abscess capsule was felt to be hampered by the size, extension, and chronology of the lesion. We hope that Drs. Gelabert and Aran-Echabe will agree with us that sometimes the optimal surgical approach has to be decided on an individual basis. Once again, we thank them for their kind comments about our article. Reference 1. Gelabert-González M, Aran-Echabe E. Brain abscess in a newborn. Pediatr Neurol. 2014;50:e13.
Jordi Pérez-Bovet, MD Patricia Puerta-Roldán, MD Gemma García-Fructuoso, MD Neurosurgery Department Hospital Sant Joan de Déu Barcelona, Spain E-mail address: [email protected]
http://dx.doi.org/10.1016/j.pediatrneurol.2014.01.053
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Letters to the Editor
Brain Abscess in a Newborn Eduardo Aran-Echabe, MD Department of Surgery University of Santiago de Compostela Santiago, Spain
To the Editor: We were interested to read the recent article by PérezBovet et al. (“Brain abscess as a cause of macrocephaly in a new born”)1 and would like to make a few comments based on our own experience with the same pathology.2 The authors state that: “Antibiotics were injected and drained. Empiric intravenous antibiotics were started.” It is important to know which antibiotics were administered in the abscess cavity. Second, we would like to know if the author’s hospital has an empirically based protocol for the antibiotic treatment of abscesses and subdural empyema. The empirical antibiotics should include coverage of anaerobic pathogens, such as a metronidazole, plus vancomycin if there is suspicion of Staphylococcus infection and cover against gram-negative pathogens (third-generation cephalosporin), especially in pediatric patients. This or a similar protocol can be administered until pus is drained and the antibiotic sensitivity reports become available; specific bactericidal agents for the organism cultured should be administered. We believe that this is important for the proper treatment of this pathology.2,3 Finally, we congratulate the authors on their result. We, as well as many authors, consider that, where possible, craniotomy with resection of the capsule is the best practice because it provides rapid improvement of neurological status, lower resurgery rates, shorter duration of postoperative antibiotic use, and shorter hospital stays. References 1. Pérez-Bovet J, da Silva-Freitas R, Puerta-Roldán P, GuillénQuesada A, Candela-Cantó S, García-Fructuoso G. Brain abscess as a cause of macrocephaly in a new born. Pediatr Neurol. 2014;50: 121-122. 2. Gelabert-González M, Serramito-Garcia R, García-Allut A, CutrinPrieto JM. Management of brain abscess in children. J Pediatr Child Health. 2008;44:731-735. 3. González-García J, Gelabert M, Pravos AG, Prieto A. Intracranial collections of pus. A review of 100 cases. Rev Neurol. 1999;29: 416-424.
Miguel Gelabert-González, PhD Neurosurgical Service Clinic Hospital of Santiago de Compostela Santiago, Spain E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pediatrneurol.2013.11.015
Brain Abscess as a Cause of Macrocephaly in a Newborn To the Editor: The authors thank Drs. Gelabert and Aran-Echabe for their interest in our report.1 We agree that empiric, broadspectrum antibiotics, followed by culture-directed therapy, is the mainstay of intracranial infection management. In answer to their question, our institution has a protocol to guide such management as we believe this constitutes standard practice. In patients with brain abscess, we use a combination of vancomycin, metronidazole, and ceftazidime, although other intracranial infections are treated with vancomycin and meropenem. Like Drs. Gelabert and Aran-Echabe, we considered that empiric therapy represents a broad-spectrum regimen, fully justified in most clinical settings. Regarding instillation of antibiotics into the abscess cavity, although no systematic approach has been studied in the literature (as far as we know), we empirically use gentamicin, again complying with institutional protocol. Finally, we agree that craniotomy is probably the surgical approach with the lowest recurrence rate, but we believe that certain clinical circumstances make less invasive approaches equally or more adequate. Discussion regarding different surgical options and optimal management is beyond the scope of our article. In the individual we described, our intention was to emphasize his particular clinical presentation, initially managed as an asymptomatic macrocephaly. Our aim was to illustrate an apparent disproportion between lesion size and alarming signs and between mass effect and neurological status. Obviously, the child was managed as an emergency as soon as he was referred to us. Neurosurgical intervention and intensive care surveillance were implemented immediately. The particular clinical setting of this patient gave us the
e14
Letters to the Editor / Pediatric Neurology 50 (2014) e13ee14
impression that craniostomy allowed immediate relief of mass effect with less risk of complications. The safe resection of the abscess capsule was felt to be hampered by the size, extension, and chronology of the lesion. We hope that Drs. Gelabert and Aran-Echabe will agree with us that sometimes the optimal surgical approach has to be decided on an individual basis. Once again, we thank them for their kind comments about our article. Reference 1. Gelabert-González M, Aran-Echabe E. Brain abscess in a newborn. Pediatr Neurol. 2014;50:e13.
Jordi Pérez-Bovet, MD Patricia Puerta-Roldán, MD Gemma García-Fructuoso, MD Neurosurgery Department Hospital Sant Joan de Déu Barcelona, Spain E-mail address: [email protected]
http://dx.doi.org/10.1016/j.pediatrneurol.2014.01.053
