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Q Q

J Med 2002; 95 :501–509

J Med 2002; 95 :501–509

Original papers

QJM

Bacterial brain abscess: microbiological features, epidemiological trends and therapeutic outcomes

C.-H. LU 1 , W.-N. CHANG 1 , Y.-C. LIN 2 , N.-W. TSAI 1 , P.-C. LILIANG 2 , T.-M. SU 2 , C.-S. RAU 2 , Y.-D. TSAI 2 , C.-L. LIANG 2 , C.-J. CHANG 3 , P.-Y. LEE 4 , H.-W. CHANG 5 and J.-J. WU 6

From the Departments of 1 Neurology, 2 Neurosurgery, 3 Pediatric Neurology, and 4 Pharmacy, Chang Gung Memorial Hospital-Kaohsiung, Kaohsiung, 5 Department of Biological Science, National Sun Yat-Sen University, and 6 Department of Medical Technology, National Cheng Kung University Medical College, Tainan, Taiwan

Received 14 February 2002 and in revised form 22 April 2002

Summary

Background: Despite the advent of modern neuro- surgical techniques, new antibiotics, and powerful imaging technologies, brain abscess remains a potentially fatal central nervous system infection. Aim: To determine the epidemiological trends, prognostic factors, and outcomes of bacterial brain abscess, to improve the therapeutic strategy for this disease. Design: Retrospective hospital-based epidemiology study. Methods: Over a period of 15 years (1986–2000), 123 patients were retrospectively identified as having brain abscesses at Kaohsiung Chang Gung Memorial Hospital. To compare changes over time, the appearance of disease among our patients was divided into two time periods: 1986–1993 and

1994–2000.

Results: The prevalence rate of brain abscesses caused by Gram-negative organisms significantly

increased in the second study period. Viridans streptococci and Klebsiella pneumoniae were the two prevalent pathogens associated with haemato- genous spread. Metastatic septic abscess, a devas- tating complication of K. pneumoniae septicaemia, frequently occurs in diabetic patients, with a high mortality rate. Viridans streptococci were the most prevalent pathogens from infection in para- nasal sinusitis, but no fatality occurred. In recent years, head trauma and/or post-neurosurgical states have become important predisposing factors, and nosocomial infections also play an important role. Discussion: Despite the availability of new anti- biotics and the development of better neurosurgical techniques, therapeutic outcomes of brain abscess showed no significant change when comparing the two study periods, and only the presence of septic shock influenced outcome.

Introduction

Despite the advent of modern neurosurgical tech- niques, new antibiotics, and new powerful imaging technologies, brain abscess remains a potentially

fatal central nervous system (CNS) infection. 14 In 1973, Kao et al. 5 reported the clinical features of 26 cases of brain abscess with surgical intervention;

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however, a large series study of brain abscess in Taiwan is still lacking. A hospital-based study provides accurate information about localization of brain abscess, predisposing factors, clinical features, the prevalence rate of implicated bacterial pathogens, and causes of fatality. In this study, we investigated differences between nosocomial and community-acquired infections, predisposing factors, clinical and neuroimaging findings, com- plications, and therapeutic outcomes, in order to improve the therapeutic strategies for this potentially fatal disease.

Methods

Over a period of 15 years (January 1986 to December 2000), 123 patients were retrospectively identified as having brain abscesses at Kaohsiung Chang Gung Memorial Hospital. The largest med- ical centre in southern Taiwan, this facility is a 2482-bed acute-care teaching hospital, which provides both primary and tertiary referral care services. Southern Taiwan consists of two cities and three counties (Kaohsiung Municipality and Hsien, Tainan City and Hsien, and Pingtung Hsien) with a population of approximately 5 441 000 as of October 1998. 6 The annual population increase for Taiwan has been reported to be 7.52 % . 6 To compare changes over time, the appearance of disease among our patients was divided into two time periods: the first time period was 8 years (January 1986–December 1993) and the was 7 years (January 1994–December 2000). Criteria of bacterial brain abscess for inclusion were: (i) characteristic computerized tomography (CT) and/or magnetic resonance imaging (MRI) findings; (ii) evidence of brain abscess seen during surgery or histopathological examination; and (iii) classical clinical manifestations including head- ache, fever, localized neurological signs and/or consciousness disturbance. 79 All materials from bacterial brain abscesses were cultured for aerobic and anaerobic bacteria, mycobacteria, and fungi. Aerobic culture media included blood, chocolate, EMB, CNA media, and thioglycolate broths. Anaerobic cultures were processed in Brucellae agar plate, BBE/PEA media, and thioglycolate broths. BHI agar, mycobiotic media, SDA media, and SCG media were used for fungal isolation. Lowenstein-Jensen media and middle 7H11 media were used for mycobacterial isolation. Organisms were identified by API (Analytab Products), RapID-ANA II identification system (Innovative Diag- nostic Systems), and ID 32 C (VITEK, bioMe´rieux

Vitex). Patients were considered to have mixed infections if at least two bacterial organisms were isolated from the initial cultures. Patients who were initially treated at other hospitals but subsequently transferred to our hospital for further therapy were also included in this study, with initial clinical data collected at those hospitals used for analysis. Brain abscesses were defined as nosocomial according to the 1988 guidelines of the Centers for Disease Control. 7 Brain abscesses related to head trauma with skull fracture or neurosurgical procedures, were classified as post-neurosurgical. Other patients who presented with no distinctive characteristics, and/or who had not undergone invasive procedures, were classified as having the spontaneous form. Patients with evidence of brain abscesses not due to bacterial pathogens were excluded from this study. The mental status for patients was classified into two groups: (i) clear consciousness; and (ii) inatten- tion, confusion, clouded consciousness, stupor, or coma. Surgical intervention and/or antibiotic ther- apy were the mainstays of our treatment. Antibiotic susceptibility was determined using the Kirby-Bauer disc diffusion method (Mueller-Hinton II agars; Becton Dickinson). Appropriate antimicrobial therapy was defined as the administration of one or more antimicrobial agents, which demonstrated effectiveness against bacterial pathogens, as deter- mined from susceptibility tests, and which were capable of passing through the blood-brain barrier in adequate amounts. Surgical treatment consisted of either aspiration or excision of the abscess. Aspiration was used to aspirate the content of the abscess with a ventricular catheter via a burr hole or small craniotomy, which left the capsule alone. Craniotomy and resection of the abscess was defined as evacuation. In our institution, those patients presenting in good neurological condition with a well-formed abscess in the right hemisphere underwent evacuation, whereas those presenting significant surgical risks or those with an abscess that was deep-seated or in the left hemisphere underwent aspiration. Recovery was evaluated 3 months after patient discharge. Data, including initial clinical manifestations, acquisition of infection, type of infection, numbers of abscesses, various treatment regimens, and fatal- ities in the two study periods, were analysed using the x 2 test or Fisher’s exact test. Data for age, and interval between onset and diagnosis between fatal and non-fatal groups were compared using Student’s t -test. Stepwise logistic regression was used to evaluate the relationship between clinical

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factors and the mortality rate adjusting for other potential confounding factors. All analyses were conducted using SAS (1990). 10

Results

The 123 patients included 92 males (mean age 43 years; range 1 month–80 years) and 31 females (mean age 41 years; range 2 months–73 years) (Figure 1). Of these 123 patients, 103 had community- acquired infections, while the other 20 were diagnosed with nosocomial infections. Sixty-nine cases appeared in the first time period (January 1986–December 1993), with the other 54 in the second time period (January 1994–December 2000) (Table 1). The ratios of community-acquired to nosocomial meningitis for these two time periods were 58:11 and 44:10, respectively. Associations for portal of entry and causative pathogens are listed in Table 2. Portal of entry for infection in 94 culture-positive brain abscesses included haematogenous spread (n = 32), postneuro- surgical states (n = 17), contiguous infection from parameningeal foci such as an otogenic origin (n = 13), paranasal sinusitis (n = 9), and unknown (n = 24). In this study, Klebsiella pneumoniae and viridans streptococci were the two most prevalent pathogens associated with haematogenous spread, accounting for 52% (15/29) of the episodes. Staphylococcus aureus, K. pneumoniae, and viridans streptococci were the three common pathogens in postneurosurgical states, accounting for 47% (7/15) of the episodes. Viridans streptococci were the most prevalent pathogens from paranasal sinusi- tis infections, while Proteus species were the common pathogens of otogenic origin, in brain abscesses with polymicrobial infection. The mean interval between onset of symptoms to detection of brain abscess was 21 days (range 1–700 days).

detection of brain abscess was 21 days (range 1–700 days). Figure 1. Age distribution of patients

Figure 1. Age distribution of patients with brain abscess.

In the first study period, 58 % (40/69) of cases

involved a single pathogen, with viridans strepto- cocci being the most prevalent (23 % ), followed by Bacteroides species (18 % ), S. aureus (10 % ), and Corynebacterium species (10 % ). Fourteen percent (10/69) of patients had mixed infections, and

26 % (18/69) of patients had a negative culture. In

the second study interval, 70 % (38/54) of cases were infected by a single pathogen, with viridans streptococci again the most prevalent (29 % ), followed by K. pneumoniae (26 % ). Eleven percent (6/54) of patients had mixed infections, and 20 % (11/54) of patients had a negative culture. Clinical manifestations of these 123 patients are listed in Table 3. Fever was found in 71 patients and headache in 68. Forty-nine patients were admitted with disturbed consciousness. Twenty- one patients suffered septic shock, 13 of whom subsequently died. Seizures and/or status epilepti- cus occurred in 23 patients, of whom five died. Concomitant bacterial meningitis was found in 29 patients. Of these 29, 24 had community-acquired infections and five had acquired the infections nosocomially. Four of the five nosocomially- infected patients had undergone neurosurgical procedures as the underlying condition; the other had had a stroke. Of these 29 cases with con- comitant bacterial meningitis, five were identified as K. pneumoniae infection and revealed multiple septic abscesses on further examination, including liver abscess, renal abscess, lung abscess, para- spinal abscess, endophthalmitis, pyomyositis, purulent pericarditis, and septic arthritis. All five of these patients were diabetic. Other clinical manifes- tations in these 123 cases included hemiparesis, stiff neck, facial palsy, hemiparaesthesia, and disturbance of speech and vision. The locations of brain abscesses of these 123 cases were supratentorial in 118 cases and infra- tentorial in five (Table 4). In total, 99 (80.5 % ) had a single brain abscess and 24 (19.5 % ) had multiple brain abscesses. The most common sites for brain abscess were the frontal lobe (33% ), followed by the temporal lobe (20% ) and temporo-parietal lobe (10 % ). The left hemisphere was involved more than the right with 63 on the left, 47 on the right, two on the midline, six bilaterally on both hemispheres, and five on the infratentorial area. Antimicrobial therapy, with or without surgical intervention (aspiration or total excision), was the cornerstone of treatment in these 123 patients. Seventeen patients received antimicrobial therapy alone, four of whom had multiple pyogenic brain abscesses; the other 13 were associated with poor systemic conditions. Penicillin G with chlor- amphenicol was the mainstay of initial empiric

*All eleven patients contracted the infection after trauma or neurosurgical procedures. **Except for two patients with K. pneumoniae infection, all the others contracted the infection after trauma or neurosurgical procedures.

Total deaths n = 21

10

0

0

0

0

0

0

0

0

0

4

4

62

32

2

2

31

31

1

1

1

Total n = 123

20

16

29

7

4

13

2

2

3

3

3

1

1

1

1

1

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Deaths n = 8

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

2

2

2

1

1

Nosocomial n = 10**

Jan 1994–Dec 2000 (n = 54)

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

2

2

3

1

1

1

Community n = 44

10

0

0

0

0

0

7

4

9

2

2

1

1

1

1

1

1

1

1

1

1

Deaths n = 13

0

0

0

0

0

0

0

0

0

0

0

0

2

2

2

2

1

1

1

1

1

Nosocomial n = 11*

Jan 1986–Dec 1993 (n = 69)

Table 1 Causative organisms, January 1986 through December 2000

0

0

0

0

0

0

0

0

0

0

0

0

2

2

1

1

1

1

1

1

1

Community n = 58

16

0

0

0

0

0

0

0

7

4

8

8

2

2

3

3

1

1

1

1

1

Gram-negative bacilli ( n = 27) Klebsiella pneumoniae Pseudomonas aeruginosa Escherichia coli Salmonella spp. Proteus spp. Enterobacter spp. Klebsiella oxytoca Vibrio cholerae non-O1 Pasteurella spp. Streptococcus species ( n = 21 ) Viridans streptococci non-A, non-B, and non-D streptococci Staphylococcus species ( n = 9) Staphylococcus aureus Coagulase-negative Staphylococcus Corynebacterium spp. (n = 4) Anaerobes (n = 17 ) Bacteroides spp. Fusobacterium spp. Peptostreptococcus spp. Peptococcus spp. Propionibacterium spp. Mixed bacterial pathogens (n = 16) Negative culture (n = 29)

Organisms

504504

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Table 2 Relation between predisposing factors and causative pathogens

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Organisms

Haematogenous

Postneurosurgical

Contiguous infection

Unknown

spread

states***

 
 
 

Otogenic

Paranasal

infection

sinusitis

Aerobic Gram-negative bacilli Klebsiella pneumoniae Pseudomonas aeruginosa Escherichia coli Salmonella spp. Proteus spp. Enterobacter spp. Klebsiella oxytoca Vibrio cholerae non-O1 Pasteurella spp. Streptococcus spp . Viridans streptococci non-A, non-B, and non-D streptococci Staphylococcus spp . Staphylococcus aureus Coagulase-negative staphylococci Corynebacterium spp. Anaerobes Bacteroides spp. Fusobacterium Peptostreptococcus spp. Peptococcus spp. Propionibacterium spp. Mixed bacterial pathogens Negative culture

9* (3)

2

1

0

1 (1)

0

1 (1)

0

0

2

2 (1)

0

0

0

1

1

1

0

0

0

0

1

1

0

0

0

1

0

0

0

0

0

100

1(1)

0

0

0

0

0

0

0

0

1

6**

2

0

6

6

1

0

0

0

0

1 (1)

3

0

0

2

2 (1)

0

0

0

1 (1)

2 (1)

0

0

0

2

1

1

2 (1)

1

2 (1)

1

1

100

1

0

0

0

0

1

0

1

0

1 (1)

0

0

0

2

1

3 1 (1)

4 2

5 3 (1) 5 (2)

0

4 4

0

2

2

20 (2)

Deaths are shown as figures in parentheses. *Seven of the nine had diabetes mellitus as the underlying disease. **Of these six, five had heart diseases, including infectious endocarditis (1), tetralogy of Fallot (2), Ebstein’s anomaly (1) and atrial septal defect (1). ***Included craniotomy due to head trauma (6), intracerebral or subdural haematoma (4), brain tumour (4), ventriculoperitoneal shunt for hydrocephalus (1). 1 Bacteroides melaninogenicus, non-A, non-B, and non-D streptococci ; viridans streptococci, Pseudomonas species ; Peptostreptococcus, Bacteroides melaninogenicus . 2 Proteus mirabilis , Enterobacter cloacae; Staphylococcus aureus, viridans streptococci; Proteus mirabilis , Escherichia coli , Serratia marcescens ; Peptostreptococcus , Bacteroides fragilis . 3 Proteus vulgaris , Klebsiella oxytoca; Bacteroides fragilis, Proteus mirabilis, Pseudomonas spp., Enterococcus spp., Group D streptococci; Bacteroides spp; Escherichia coli, Proteus mirabilis , Corynebacterium , Bacteroides spp.; Peptococcus, Veillonella spp.; Enterococcus, Staphylococcus aureus, non-A, non-B, and non-D streptococci; viridans streptococci, Klebsiella pneumoniae . 4 Bacillus , Fusobacterium nucleatum ; Prevotella intermedia, Fusobacterium nucleatum , viridans streptococci; Bacteroides fragilis , Proteus mirabilis ; viridans streptococci, Peptococcus.

antimicrobial treatment of bacterial brain abscess unless Staphylococcus or Gram-negative bacilli were more likely to be the responsible pathogens. The choice of final antibiotics was guided by the final culture results. With this regimen of therapy, 12 patients experienced recurrence of brain abscesses, and they received repeated aspiration and/or total excision of brain abscesses. In total, 102/123 patients survived. Mortality rates for the first and second study periods were 19 % and 15 % , respectively (Figure 2). Nine of 67 patients who received both antimicrobial therapy and total excision died. Six of 33 patients who received

both antimicrobial therapy and aspiration died. All six patients who received antimicrobial therapy and aspiration with subsequent total excision survived,

while there were six fatalities among the 17 patients who received antimicrobial therapy alone. Mortality rates of patients by group of causative organism were as follows: Gram-negative bacilli,

27 % (7/26); Streptococcus spp., 0% (0/21);

Staphylococcus spp., 33 % (3/9); Corynebacterium spp., 25 % (1/4); anaerobic pathogens, 17 % (3/18); mixed bacterial species, 13 % (2/16); and negative cultures, 14 % (4/29) (Table 1). Of the 21 patients who died, 13 had fulminant clinical courses and

506506

Table 3 Clinical manifestations

C.-H.C.-H. LuLu etet al.al.

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Community-acquired

Nosocomial

Total ( n = 123) (d = 21)

(n

= 102) ( d = 20)

(n = 21) ( d = 1)

Fever/chills Headache Disturbed consciousness Hemiparesis Nausea/vomiting Stiff neck Speech disturbance Seizure Septic shock Visual disturbance Facial palsy Hemiparaesthesia

60

11

71

63

5

68

44

15

59

44

10

54

35

4

39

33

3

36

22

3

25

18

5

23

20

1

21

17

1

18

8

1

9

7

1

8

d, deaths.

Table 4 Localization of brain abscesses

Localization

Number of cases

(n

= 123) ( %)

Single site Frontal lobe Temporal lobe Temporo-parietal area Basal ganglion Occipital lobe Parieto-occipital area Fronto-parietal area Parietal lobe Cerebellum Cerebellopontine angle Third ventricle Intrasellar area Total Multiple sites

33

20

10

8

6

6

5

4

4

1

1

1

99 (80.5 %) 24 (19.5 %)

4 4 1 1 1 99 (80.5 % ) 24 (19.5 % ) Figure 2. Numbers

Figure 2. Numbers of fatal and non-fatal cases of bacterial brain abscess, distributed over 15 years.

deterioration of systemic conditions, three had intracerebral haemorrhage after surgical interven- tions, and four had brain swelling with subsequent

herniation. Among the 102 survivors, 64 resumed normal lives or had mild mental abnormalities, 27 had focal neurological deficits with moderate disability, and 11 had severe disability or were in a persistent vegetative state. The potential prognostic factors of these 123 patients are listed in Table 5. According to the statistical analysis, only the presence of septic shock (p - 0.001) had a significant influence on therapeu- tic outcomes. Variables, including age at infection, sex, acquisition of infection, type of infection, type of treatment, headache, fever, septic shock, seizure, concomitant meningitis, mental status, and the interval between onset and diagnosis, were used in the stepwise logistic regression, and the presence of septic shock ( p = 0.0001) was the only factor predictive of mortality.

Discussion

The causative pathogens of bacterial brain abscess vary with time period, geographic distribution, age, underlying medical and/or surgical conditions, and mode of infection. 15 The relative frequency of mixed bacterial infections and limitations of anae- robic culture techniques also influence the patho- gen prevalence in different studies. 114 A study from China reported that Gram-negative bacilli, with Proteus , Enterobacter and Alcaligenes species being common, accounted for 21 % (82/400) of the implicated pathogens of brain abscess from 1952 to 1972. 14 In one early study of brain abscess from Taiwan, Gram-negative bacilli, Staphylococcus

Table 5 Prognostic factors

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Prognostic factor

Patients

Dead

Alive

p

OR

95%CI

Statistical test

(1) Age at infection (mean, years) All (2) Sex Male Female (3) Acquisition of infection Community Nosocomial (4) Type of infection Spontaneous meningitis Postneurosurgical meningitis (5) Types of treatment Excision and antimicrobial Aspiration and antimicrobial Antimicrobial alone Aspiration then excision plus antibiotics (6) Clinical manifestations Headache Yes No Fever Yes No Septic shock Yes No Seizure Yes No Focal neurological deficits* Yes No Concomitant meningitis Yes No Mental status Group I Group II

 

49.0

40.8

0.079

Student’s t

92

16

76

0.875

1.10

0.37–3.28

x 2

31

5

26

102

20

82

0.121

4.88

0.62–38.54

Fisher’s exact

21

1

20

104

20

84

0.192

4.29

0.54–34.03

Fisher’s exact

19

1

18

66

9

57***

0.165

2.15

0.11–41.33

Fisher’s exact

34

6

28

2.97

0.15–59.55

17

6

11

7.35

0.35–152.53

6

06

 

68

10

58

0.477

0.69

0.27–1.77

x

2

55

11

44

71

15

56

0.163

2.05

0.74–5.72

x

2

52

6

46

21

13

8

-0.001**

19.10

6.11–59.63

Fisher’s exact

102

8

94

23

5

18

0.542

1.46

0.47–4.50

Fisher’s exact

100

16

84

78

14

64

0.734

1.19

0.44–3.20

x

2

45

7

38

29

3

26

0.40

0.49

0.13–1.79

x

2

94

18

76

64

11

53

0.972

1.02

0.40–2.60

x

2

59

10

49

(7) Interval between onset and diagnosis (mean, days)

All

10.6

23.2

0.11

Student’s t

*Focal neurological deficits included hemiparesis, facial palsy, hemiparesthesia, and disturbance of speech and vision. **Statistically significant. ***Relative to aspiration then excision plus antibiotics treatment.

species, and Streptococcus species accounted for 40% (10/25) of the episodes, 5 and these three groups of pathogens also accounted for 46 % (56/123) of the pathogens implicated in this study. Of the Streptococcus species, viridans streptococci were the most frequently found, at 13 % (9/69) and 22 % (12/54) of the implicated pathogens in the first and second study time periods, respec- tively. Although there was a change in the relative frequency of pathogens, viridans streptococci

remained the most prevalent pathogens in both time periods. Among the Gram-negative bacilli, K. pneumoniae , E. coli , P. aeruginosa , and other rare Gram-negative organisms accounted for more than 21 % of implicated pathogens. There was a significantly increased prevalence of Gram-negative organisms of from 13 % (9/69) in the first to 31 % (17/54) in the second time period. This study shows that clinical presentations and underlying disorders vary greatly in brain abscesses

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due to different species. K. pneumoniae was the most prevalent pathogen associated with haemato- genous spread or postneurosurgical states. Multiple metastatic septic abscesses were common in patients with brain abscess due to K. pneumoniae . Although the reason is unknown, this association of Klebsiella infection with metastatic abscesses has been noted in other reports from Taiwan. 1517 Of the brain abscesses caused by Streptococcus species, viridans streptococci, the most prevalent members of the flora in the upper respiratory tract, gastrointestinal tract, and female genital tract, accounted for 95 % of strains. This study also shows that viridans streptococci are the prevalent pathogens with haematogenous spread secondary to cardiogenic origin or from infection of paranasal sinusitis; this finding is consistent with those of other reports. 18,19 In this study, no deaths due to viridans streptococci occurred, which may well be due to the low virulence of viridans strepto- cocci. 18,20 In the brain abscesses of otogenic origin, Proteus species were the most commonly impli- cated pathogens among the brain abscesses with polymicrobial infection, and this phenomenon was also noted in other studies. 13,21 This study also showed that S. aureus , viridans streptococci, and K. pneumoniae were the most prevalent pathogens in patients with post-neurosurgical states. Regarding the portal of entry, brain abscess is almost always secondary to a focus of suppuration elsewhere in the body, and may develop either by a contiguous focus of infection, head trauma, or haematogenous spread from a distant focus. Although head trauma or neurosurgical procedures were once unusual as causes of brain abscesses, they were important in this study. As a previous report 12 demonstrated and our study confirms, when haematogenous spread is the source of the brain abscess, this infection is frequently community- acquired, and is commonly associated with under- lying diseases and with more fulminant courses, as evidenced by higher rates for shock and death. By contrast, postneurosurgical causes and a contiguous focus of infection are associated with a favourable outcome. In our 123 cases with brain abscesses; fever, headache, altered consciousness, and hemiparesis were the most common manifestations, occurring in 58% , 55% , 50 % , and 44% of our patients, respectively. The presence of focal neurological findings (e.g. hemiparesis, hemisensory deficits, and aphasia) depends on the location of the abscess, and these signs were seen in approximately 63 % (78/123) of our cases, while 37 % (45/123) had no localized signs. The presence of septic shock significantly influenced the outcome of our patients.

However, the presence of fever, headache, seizure, and focal neurological signs showed no statistical significance on the prognosis in our study. The interval between onset of symptom and signs and diagnosis was of no statistical significance in our study, as in a previous study. 12 Metastatic abscesses are commonly located in the parietal, frontal, or temporal lobes, 12,14 and multiple brain abscesses are usually the result of metastatic spread from remote primary foci, accounting for 6 % to 22 % of cases. 12,14 In this study, the most common cause of brain abscesses was haematogenous spread, accounting for 26 % (32/123) of the episodes, a figure higher than the study from China. 14 Almost all abscesses were found in the frontal, temporal, and parietal lobes, and multiple abscesses were present in 19.5 % (24/123). Although brain abscesses associated with neurosurgical procedures were once considered uncommon, 2,14 they accounted for 12 % of the episodes in this study. The increasing frequency of neurosurgical procedures may be due to the increasing number of neurosurgeons, the improve- ment of neurosurgical facilities, and the large number of patients with head injury from motor- cycle accidents. Unlike the data shown in one study from China, 14 where the majority of the abscesses were temporal and cerebellar, suggesting otogenic spread, our patients had more frontal disease. This may reflect the trend towards better and more aggressive management of otogenic disorders between the 1970s and the 1990s. Treatment of brain abscess requires a combina- tion of antimicrobials, surgical intervention, and eradication of primary infected foci. In Taiwan, initial empirical antibiotics with third-generation cephalosporins in combination with metronidazole, should be considered for the majority of abscesses cases resulting from infection with Gram-negative bacilli and streptococcal species. Different the- rapeutic regimens show no significant statistic differences in prognosis in other reports, 12 and were also of no statistical significance in this study. In summary, the clinical presentations, under- lying conditions and therapeutic outcomes vary greatly in brain abscesses, according to the different pathogens. In recent years, head trauma and/or post-neurosurgical states have become important predisposing factors of brain abscess, and noso- comial infections are also important. Despite the availability of new antibiotics and the development of better neurosurgical techniques, therapeutic outcomes of brain abscess have not shown a statistically significant change, and only the presence of septic shock is a prognostic factor.

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References

1. Bidzinski J, Koszewski W. The value of different methods of treatment of brain abscess in the CT era. Acta Neurochir (Wien) 1990; 105:117–20.

2. Mathisen GE, Johnson JP. Brain abscess. Clin Infect Dis 1997; 25:763–81.

3. Rosenblum ML, Hoff JT, Norman D, Weinstein PR, Pitts L. Decreased mortality from brain abscess since advent of computerized tomography. J Neurosurg 1978; 59:658–63.

4. Stephanov S. Surgical treatment of brain abscess. Neurosurg 1988; 22:724–30.

5. Kao MC. Brain abscess: a clinical analysis of 26 cases with surgical treatment. Bull Tokyo Med Dent Univ 1973;

20:35–50.

6. Ministry of the Interior, ROC. Taiwan-Fukien Demography Quarterly 1999; 25(4):14–16.

7. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control 1988; 16:128–40.

8. New PFJ, Davis KR, Ballantine HT Jr. Computed tomography in cerebral abscess. Radiology 1976; 121:641–6.

9. Rosenblum ML, Hoff JT, Norman D, Edwards MS, Berg BO. Nonoperative treatment of brain abscesses in selected high-risk patients. J Neurosurg 1980; 52:217–25.

10. SAS. SAS Users Guide. SAS Statistical Institute, Cary NC,

1990.

11. Beller AJ, Sahar A, Praiss I. Brain abscess: review of 89 cases over a period of 30 years. J Neurol Neurosurg Psych 1973;

36:757–68.

12. Chun CH, Johnson JD, Hofstetter M, Raff MJ. Brain abscess: a study of 45 consecutive cases. Medicine (Baltimore) 1986;

65:415–31.

13. de Louvis J, Gortvai P, Hurley R. Bacteriology of abscesses of the central nervous system: a multicentre prospective study. Br Med J 1977; 2:981–4.

14. Yang SY. Brain abscess: a review of 400 cases. J Neurosurg 1981; 55:794–9.

15. Tang LM, Chen ST, Hsu WC, Chen CM. Klebsiella meningitis in Taiwan: an overview. Epidemiol Infect 1997;

119:135–42.

16. Wang JH, Liu YC, Lee SS, Yen MY, Chen YS, Wang JH, Wann SR, Lin HH. Primary liver abscess due to

Klebsiella pneumoniae in Taiwan. Clin Infect Dis 1998;

6 :1434–8.

17. Wang LS, Lee FY, Cheng DL, Liu CY, Hinthorn DR, Lost PM. Klebsiella pneumoniae bacteremia: analysis of 100 episodes. J Formosan Med Assoc 1990; 89:756–63.

18. Enting RH, de Gans J, Blankevoort JP, Spanjaard L. Meningitis due to viridans streptococci in adult. J Neurol 1997; 244:435–8.

19. Pruitt A, Rubin MH, Karchmer AW, Duncan GW. Neurologic complications of bacterial endocarditis. Medicine (Baltimore) 1978; 57:329–43.

20. Cabello C, Viladrich PF, Corredoira J, Verdaguer R, Ariza J, Gudiol F. Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum. Clin Infect Dis 1999;

28:1104–8.

21. Kangsanarak J, Navacharoen N, Fooanant S, Ruckphaopunt K. Intracranial complications of suppurative otitis Media: 13 years’ experience. Am J Otol 1995; 16:104–9.