Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected epidural abscess

1st line – empiric antibiotic therapy

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INITIAL
|
suspected epidural abscess
1st line – 

empiric antibiotic therapy

Empiric antibiotic therapy should be started and continued until the causative agent is identified. Every attempt to obtain bacteriologic specimens should be completed first. Antibiotics include agents active against Staphylococcus aureus, including MRSA and aerobic gram-negative organisms.[2][30][44]

A suggested regimen is vancomycin plus either a third- or fourth-generation cephalosporin (e.g., cefotaxime, ceftriaxone, cefepime, or ceftazidime) or piperacillin/tazobactam. In patients at high risk of Pseudomonas species infection (e.g., history of intravenous drug use), cefepime, ceftazidime, or piperacillin/tazobactam is recommended.[2]

Identification and prompt treatment of the causative organism is paramount; subsequent choice of antibiotic depends on the results of microbiologic culture and susceptibility testing.

Primary options

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

-- AND --

cefotaxime: 2 g intravenously every 6-8 hours

or

ceftriaxone: 2 g intravenously every 12-24 hours

or

cefepime: 2 g intravenously every 8-12 hours

or

ceftazidime sodium: 2 g intravenously every 8 hours

or

piperacillin/tazobactam: 3.375 to 4.5 g intravenously every 6 hours

More

Consider – antifungal agent

Back
INITIAL
|
suspected epidural abscess
Consider – 

antifungal agent

Treatment recommended for SOME patients in selected patient group

Patients with underlying comorbidities (e.g., diabetes mellitus, intravenous drug use, HIV infection) or with preexisting systemic infections (e.g., infective endocarditis) are at greater risk of chronic spinal infection. In such patients, resistant or unusual pathogens (e.g., fungi) should also be considered.[49][50]

Patients with risk factors for fungal SEA should also receive an antifungal agent such as voriconazole or amphotericin-B.[2]

A lipid formulation of amphotericin B (e.g., liposomal) is preferred because it has lower nephrotoxicity than the original formulation, and allows higher doses to be given for serious fungal infections.

Primary options

voriconazole: consult specialist for guidance on dose

OR

amphotericin B liposomal: consult specialist for guidance on dose

Consider – decompressive surgery

Back
INITIAL
|
suspected epidural abscess
Consider – 

decompressive surgery

Treatment recommended for SOME patients in selected patient group

Indicated when the patient presents with progressive neurologic deficit or does not respond to antibiotic therapy.[5][14][15][16]​​​​[44]​​[52]​​[53]​​​[55]​ The single most important predictor of final neurologic outcome is patient's neurologic status immediately before decompressive surgery.

The type of surgical approach is guided in part by the imaging results. Surgery is usually performed with an open technique allowing for cord decompression, epidural irrigation, and sampling of the tissues for microbial diagnosis. For example, a focal posteriorly placed collection will yield to a single- or double-level laminectomy. For patients with less disabling symptoms, computed tomography-guided needle aspiration of intradiscal/intra-osseous lesions may be performed.

While it is recognized that delayed surgery (24-36 hours following onset of neurologic symptoms) is less effective than surgery performed early, it may still be considered for source control or if neurologic symptoms are progressive and there is evidence of cord function.[5][55]

Consider – management of hypotension

Back
INITIAL
|
suspected epidural abscess
Consider – 

management of hypotension

Treatment recommended for SOME patients in selected patient group

Patients with evidence of septic shock require correction of hypotension.

Treatment consists of central line placement and volume resuscitation.

Vasoactive drugs (vasopressors/inotropes) are recommended only if hypotension is refractory to adequate volume resuscitation.

Consult specialist for guidance on choice of suitable vasopressor regimen and dose.

See Shock.

Consider – venous thromboembolism prophylaxis

Back
INITIAL
|
suspected epidural abscess
Consider – 

venous thromboembolism prophylaxis

Treatment recommended for SOME patients in selected patient group

Patients at increased risk of thrombosis should be given prophylaxis to prevent venous thromboembolism and possible pulmonary embolism.[57] Treatment should begin no later than 72 hours after presentation. Pharmacologic prophylaxis should be used unless contraindicated; nonpharmacologic measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding.[57]

See Venous thromboembolism (VTE) prophylaxis.

ACUTE

with methicillin-sensitive Staphylococcus aureus (MSSA) infection

1st line – nafcillin or cefazolin

Back
ACUTE
|
with methicillin-sensitive Staphylococcus aureus (MSSA) infection
1st line – 

nafcillin or cefazolin

Antibiotic regimens most commonly include nafcillin or a first-generation cephalosporin (e.g., cefazolin). Nafcillin is effective against MSSA and streptococci. Cefazolin is effective against MSSA, streptococci, and susceptible aerobic gram-negative bacteria.

Throughout the course of antibiotic treatment, the patient should be monitored at least every 2 weeks for evidence of refractory infection. Serial monitoring of white blood cell count, C-reactive protein, and erythrocyte sedimentation rate is recommended to assess treatment response.[9][47]

Imaging should be repeated if laboratory values do not indicate a response to therapy or if symptoms (e.g., back pain) worsen or new neurologic deficit develops.[48][58]​ Surgical consultation should also be sought.[12][31][59]

Total duration of antibiotic treatment varies from 4 to 16 weeks, depending on several factors such as comorbidities and concurrent presence of vertebral osteomyelitis.[2] Most patients receive a minimum of 2 to 4 weeks of parenteral antibiotics, which may be extended if vertebral osteomyelitis is suspected.[2][9][30]

Primary options

nafcillin: 2 g intravenously every 4 hours

Secondary options

cefazolin: 2 g intravenously every 8 hours

Consider – decompressive surgery

Back
ACUTE
|
with methicillin-sensitive Staphylococcus aureus (MSSA) infection
Consider – 

decompressive surgery

Treatment recommended for SOME patients in selected patient group

Indicated when the patient presents with progressive neurologic deficit or does not respond to antibiotic therapy.[5][14][15][16]​​​​[44]​​[52]​​[53]​​​[55]​ The single most important predictor of final neurologic outcome is patient's neurologic status immediately before decompressive surgery.

The type of surgical approach is guided in part by the imaging results. Surgery is usually performed with an open technique allowing for cord decompression, epidural irrigation, and sampling of the tissues for microbial diagnosis. For example, a focal posteriorly placed collection will yield to a single- or double-level laminectomy. For patients with less disabling symptoms, computed tomography-guided needle aspiration of intradiscal/intra-osseous lesions may be performed.

While it is recognized that delayed surgery (24-36 hours following onset of neurologic symptoms) is less effective than surgery if performed early, it may still be considered for source control or if neurologic symptoms are progressive and there is evidence of cord function.[5][55]

Consider – management of hypotension

Back
ACUTE
|
with methicillin-sensitive Staphylococcus aureus (MSSA) infection
Consider – 

management of hypotension

Treatment recommended for SOME patients in selected patient group

Patients with evidence of septic shock require correction of hypotension.

Treatment consists of central line placement and volume resuscitation.

Vasoactive drugs (vasopressors/inotropes) are recommended only if hypotension is refractory to adequate volume resuscitation.

Consult specialist for guidance on choice of suitable vasopressor regimen and dose.

See Shock.

Consider – venous thromboembolism prophylaxis

Back
ACUTE
|
with methicillin-sensitive Staphylococcus aureus (MSSA) infection
Consider – 

venous thromboembolism prophylaxis

Treatment recommended for SOME patients in selected patient group

Patients at increased risk of thrombosis should be given prophylaxis to prevent venous thromboembolism and possible pulmonary embolism.[57] Treatment should begin no later than 72 hours after presentation. Pharmacologic prophylaxis should be used unless contraindicated; nonpharmacologic measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding.[57]

See Venous thromboembolism (VTE) prophylaxis.

with MRSA infection

1st line – vancomycin ± rifampin or trimethoprim/sulfamethoxazole or linezolid

Back
ACUTE
|
with MRSA infection
1st line – 

vancomycin ± rifampin or trimethoprim/sulfamethoxazole or linezolid

First-line antibiotic therapy is vancomycin. Some experts recommend adding rifampin to vancomycin.[45]

Second-line options include trimethoprim/sulfamethoxazole and linezolid.[45][46]​ These may be used due to vancomycin allergy/intolerance or if there is a need to switch to an oral antibiotic earlier than planned (e.g., due to social reasons, patient’s refusal to receive intravenous antibiotics, or lack of intravenous access).

Throughout the course of antibiotic treatment, the patient should be monitored at least every 2 weeks for evidence of refractory infection. Serial monitoring of white blood cell count, C-reactive protein, and erythrocyte sedimentation rate is recommended to assess treatment response.[9][47]​ Imaging should be repeated if laboratory values do not indicate a response to therapy, or if symptoms (e.g., back pain) worsen or new neurologic deficit develops.[48][58]​ Surgical consultation should also be sought.[12][31][59]

Total duration of antibiotic treatment varies from 4 to 16 weeks, depending on several factors such as comorbidities and concurrent presence of vertebral osteomyelitis.[2] Most patients receive a minimum of 2 to 4 weeks of parenteral antibiotics, which may be extended if vertebral osteomyelitis is suspected.[2][9][30]

Primary options

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

OR

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

and

rifampin: 600 mg intravenously/orally every 24 hours; 300-450 mg orally every 12 hours

Secondary options

sulfamethoxazole/trimethoprim: 4 mg/kg intravenously/orally twice daily

More

OR

linezolid: 600 mg intravenously/orally every 12 hours

Consider – decompressive surgery

Back
ACUTE
|
with MRSA infection
Consider – 

decompressive surgery

Treatment recommended for SOME patients in selected patient group

Indicated when the patient presents with progressive neurologic deficit or does not respond to antibiotic therapy.[5][14][15][16]​​​[44]​​[52]​​[53]​​​[55]​ The single most important predictor of final neurologic outcome is patient's neurologic status immediately before decompressive surgery.

The type of surgical approach is guided in part by the imaging results. Surgery is usually performed with an open technique allowing for cord decompression, epidural irrigation, and sampling of the tissues for microbial diagnosis. For example, a focal posteriorly placed collection will yield to a single- or double-level laminectomy. For patients with less disabling symptoms, computed tomography-guided needle aspiration of intradiscal/intra-osseous lesions may be performed.

While it is recognized that delayed surgery (24-36 hours following onset of neurologic symptoms) is less effective than surgery performed early, it may still be considered for source control or if neurologic symptoms are progressive and there is evidence of cord function.[5][55]

Consider – management of hypotension

Back
ACUTE
|
with MRSA infection
Consider – 

management of hypotension

Treatment recommended for SOME patients in selected patient group

Patients with evidence of septic shock require correction of hypotension.

Treatment consists of central line placement and volume resuscitation.

Vasoactive drugs (vasopressors/inotropes) are recommended only if hypotension is refractory to adequate volume resuscitation.

Consult specialist for guidance on choice of suitable vasopressor regimen and dose.

See Shock.

Consider – venous thromboembolism prophylaxis

Back
ACUTE
|
with MRSA infection
Consider – 

venous thromboembolism prophylaxis

Treatment recommended for SOME patients in selected patient group

Patients at increased risk of thrombosis should be given prophylaxis to prevent venous thromboembolism and possible pulmonary embolism.[57] Treatment should begin no later than 72 hours after presentation. Pharmacologic prophylaxis should be used unless contraindicated; nonpharmacologic measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding.[57]

See ​Venous thromboembolism (VTE) prophylaxis.

with gram-negative infection

1st line – intravenous antibiotic therapy

Back
ACUTE
|
with gram-negative infection
1st line – 

intravenous antibiotic therapy

First-line antibiotic therapy is usually a third- or fourth-generation cephalosporin (e.g., cefotaxime, ceftriaxone, cefepime, or ceftazidime) or piperacillin/tazobactam. When Pseudomonas species infection is suspected, cefepime, ceftazidime, or piperacillin/tazobactam is recommended.

Throughout the course of antibiotic treatment, the patient should be monitored at least every 2 weeks for evidence of refractory infection. Serial monitoring of white blood cell count, C-reactive protein, and erythrocyte sedimentation rate is recommended to assess treatment response.[9][47]​ Imaging should be repeated if laboratory values do not indicate a response to therapy, or if symptoms (e.g., back pain) worsen or new neurologic deficit develops.[48][58]​ Surgical consultation should be sought.[12][31][59]

Total duration of antibiotic treatment varies from from 4 to 16 weeks, depending on several factors such as comorbidities and concurrent presence of vertebral osteomyelitis.[2] Most patients receive a minimum of 2 to 4 weeks of parenteral antibiotics, which may be extended if vertebral osteomyelitis is suspected.[2][9][30]

Primary options

cefotaxime: 2 g intravenously every 6-8 hours

OR

ceftriaxone: 2 g intravenously every 12-24 hours

OR

cefepime: 2 g intravenously every 8-12 hours

OR

ceftazidime sodium: 2 g intravenously every 8 hours

OR

piperacillin/tazobactam: 3.375 to 4.5 g intravenously every 6 hours

More

Consider – decompressive surgery

Back
ACUTE
|
with gram-negative infection
Consider – 

decompressive surgery

Treatment recommended for SOME patients in selected patient group

Indicated when the patient presents with progressive neurologic deficit or does not respond to antibiotic therapy.[5][14][15][16]​​​[44]​​[52]​​[53]​​​[55]​ The single most important predictor of final neurologic outcome is patient's neurologic status immediately before decompressive surgery.

The type of surgical approach is guided in part by the imaging results. Surgery is usually performed with an open technique allowing for cord decompression, epidural irrigation, and sampling of the tissues for microbial diagnosis. For example, a focal posteriorly placed collection will yield to a single- or double-level laminectomy. For patients with less disabling symptoms, computed tomography-guided needle aspiration of intradiscal/intra-osseous lesions may be performed.

While it is recognized that delayed surgery (24-36 hours following onset of neurologic symptoms) is less effective than surgery if performed early, it should still be considered for source control or if neurologic symptoms are progressive and there is evidence of cord function.[5][55]

Consider – management of hypotension

Back
ACUTE
|
with gram-negative infection
Consider – 

management of hypotension

Treatment recommended for SOME patients in selected patient group

Patients with evidence of septic shock require correction of hypotension.

Treatment consists of central line placement and volume resuscitation.

Vasoactive drugs (vasopressors/inotropes) are recommended only if hypotension is refractory to adequate volume resuscitation.

Consult specialist for guidance on choice of suitable vasopressor regimen and dose.

See Shock.

Consider – venous thromboembolism prophylaxis

Back
ACUTE
|
with gram-negative infection
Consider – 

venous thromboembolism prophylaxis

Treatment recommended for SOME patients in selected patient group

Patients at increased risk of thrombosis should be given prophylaxis to prevent venous thromboembolism and possible pulmonary embolism.[57] Treatment should begin no later than 72 hours after presentation. Pharmacologic prophylaxis should be used unless contraindicated; nonpharmacologic measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding.[57]

See Venous thromboembolism (VTE) prophylaxis.

with Mycobacterium tuberculosis infection

1st line – antituberculous therapy

Back
ACUTE
|
with Mycobacterium tuberculosis infection
1st line – 

antituberculous therapy

Patients should receive 6 months to 1 year of appropriate antituberculous therapy.

See Pulmonary tuberculosis and HIV-related opportunistic infections.

Throughout the course of treatment, the patient should be monitored at least every 2 weeks for evidence of refractory infection. Serial monitoring of C-reactive protein and erythrocyte sedimentation rate is recommended to assess treatment response.[9][47]​ Imaging should be repeated if laboratory values do not indicate a response to therapy, or if symptoms (e.g., back pain) worsen or new neurologic deficit develops.[48][58]​ Surgical consultation should be sought.[12][31][59]

Consider – decompressive surgery

Back
ACUTE
|
with Mycobacterium tuberculosis infection
Consider – 

decompressive surgery

Treatment recommended for SOME patients in selected patient group

Indicated when the patient presents with progressive neurologic deficit or does not respond to antibiotic therapy.[5][14][15][16]​​​[44]​​[52]​​[53]​​​[55]​ The single most important predictor of final neurologic outcome is patient's neurologic status immediately before decompressive surgery.

The type of surgical approach is guided in part by the imaging results. Surgery is usually performed with an open technique allowing for cord decompression, epidural irrigation, and sampling of the tissues for microbial diagnosis. For example, a focal posteriorly placed collection will yield to a single- or double-level laminectomy. For patients with less disabling symptoms, computed tomography-guided needle aspiration of intradiscal/intra-osseous lesions may be performed.

While it is recognized that delayed surgery (24-36 hours following onset of neurologic symptoms) is less effective than if performed early, it may still be considered for source control or if neurologic symptoms are progressive and there is evidence of cord function.[5][55]

Consider – management of hypotension

Back
ACUTE
|
with Mycobacterium tuberculosis infection
Consider – 

management of hypotension

Treatment recommended for SOME patients in selected patient group

Patients with evidence of septic shock require correction of hypotension.

Treatment consists of central line placement and volume resuscitation.

Vasoactive drugs (vasopressors/inotropes) are recommended only if hypotension is refractory to adequate volume resuscitation.

Consult specialist for guidance on choice of suitable vasopressor regimen and dose.

See Shock.

Consider – venous thromboembolism prophylaxis

Back
ACUTE
|
with Mycobacterium tuberculosis infection
Consider – 

venous thromboembolism prophylaxis

Treatment recommended for SOME patients in selected patient group

Patients at increased risk of thrombosis should be given prophylaxis to prevent venous thromboembolism and possible pulmonary embolism.[57] Treatment should begin no later than 72 hours after presentation. Pharmacologic prophylaxis should be used unless contraindicated; nonpharmacologic measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding.[57]

See Venous thromboembolism (VTE) prophylaxis.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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