Standard regimen for spinal epidural abscess in adults

Start empirical therapy for spinal epidural abscess as soon as possible. Do not delay for surgery. For adults who do not have implanted spinal prosthetic material or have not had a recent spinal procedure, while awaiting susceptibility results, use:

flucloxacillin 2 g intravenously, 6-hourly. For patients with suspected meningitis or for critically ill patients, use a 4-hourly dosing interval¹. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment. See advice on modification and duration of therapy flucloxacillin flucloxacillin flucloxacillin

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ceftriaxone 2 g intravenously, daily. For patients with suspected meningitis or for critically ill patients, use a 12-hourly dosing interval². See advice on modification and duration of therapy. ceftriaxone ceftriaxone ceftriaxone

Add vancomycin to the above regimen if:

there is an increased risk of methicillin-resistant Staphylococcus aureus (MRSA)
there is evidence of neurological compromise
surgery is likely to be delayed.

If vancomycin is indicated, add to the above regimen:

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, while awaiting susceptibility results, use:

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vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

For patients who have had severe immediate³ hypersensitivity reaction to a penicillin, ceftriaxone (at the dosage above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For patients who have had a severe (immediate)³ hypersensitivity reaction to a penicillin in whom ceftriaxone is not used, or for patients who have had a severe delayed⁴ hypersensitivity reaction to a penicillin, while awaiting susceptibility results, use:

ciprofloxacin 400 mg intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. See advice on modification and duration of therapy ciprofloxacin ciprofloxacin ciprofloxacin

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vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

¹ Some patients with spinal epidural abscess will be critically ill or might be suspected to have meningitis. To ensure adequate drug exposure in these patients, a modified dosage of flucloxacillin is recommended. This is because pharmacokinetics may be altered in critical illness (eg because of enhanced kidney clearance or changes in volume of distribution). Once the critical illness has resolved or meningitis has been excluded, consider switching to the standard dosage.Return

² Some patients with spinal epidural abscess will be critically ill or might be suspected to have meningitis. To ensure adequate drug exposure in these patients, a modified dosage of ceftriaxone is recommended. This is because pharmacokinetics may be altered in critical illness (eg because of enhanced kidney clearance or changes in volume of distribution). Once the critical illness has resolved or meningitis has been excluded, consider switching to the standard dosage.Return

³ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

⁴ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return