Nonoperative treatment of brain abscesses in selected high-risk patients

✓ In a series of eight high-risk patients, presumed intraparenchymal pyogenic brain abscesses resolved or decreased markedly in size with antibiotic therapy and without surgery. Cases were selected for antibiotic trial because of multiplicity or location of the abscesses and complicating medical conditions. Patients were alert or lethargic, with stable or improving early clinical courses. Diagnosis was made by computerized tomography (CT) brain scans and corroborative laboratory and diagnostic studies. Cases were closely monitored with serial CT scans. In six cases, bacteria were cultured from blood, cerebrospinal fluid, or fluid aspirated from one of multiple abscesses. Antibiotics were selected for specificity against the cultured organism, or consisted of high-dose penicillin plus chloramphenicol; therapy continued for a median of 7 weeks. Serial CT scans showed decreased abscess size by a mean of 2.4 weeks (range, 1 to 4 weeks) and resolution of contrast-enhancement and mass effects by a mean of 9.8 weeks (range, 8 to 14 weeks). Abscesses followed to resolution were significantly smaller (mean, 1.7 cm diameter, p < 0.01) than those not responding to similar courses of antibiotic therapy (mean, 4.2 cm diameter). Two patients died of causes unrelated to their abscesses; surviving patients have no neurological deficit (mean follow-up period, 25 months; range, 15 to 37 months). Guidelines are recommended for a treatment protocol to be cautiously applied for high-risk patients with small abscesses. Surgery is recommended in all other cases of pyogenic brain abscesses.