Ongoing management and duration of therapy for spinal epidural abscess in adults

Modify therapy according to the results of culture and susceptibility testing of operative material.

If a microbiological diagnosis is not obtained, modify empirical therapy based on the most likely cause and whether ambulatory antimicrobial therapy is being considered.

In patients following the standard regimen, if there is a low risk of flucloxacillin resistant staphylococci or gram-negative organisms, use intravenous flucloxacillin alone. If there is a high risk of flucloxacillin resistant staphylococci or other organisms, seek expert advice for antibiotic choice.

Continue therapy for at least 6 weeks (intravenous + oral), with a minimum of 2 weeks of intravenous treatment. If early switch to oral antibiotics is being considered, seek expert advice. The total duration depends on:

• whether the abscess was surgically drained
• the clinical response
• susceptibility of the pathogen
• presence of implanted material
• radiological evidence of improvement or resolution.

It may be appropriate to switch to oral therapy after a minimum of 2 weeks of intravenous therapy in patients who are clinically improving. A switch to oral therapy depends on:

• the patient’s suitability for oral therapy, including being
  • clinically stable
  • able to tolerate oral intake with no concerns about malabsorption
  • likely to adhere to oral therapy
• the availability of an oral antimicrobial that meets the following criteria
  • treats the identified or expected organism
  • has good bioavailability and is able to be given at a high enough dose to achieve adequate exposure at the target site for the relevant organism – see Oral and enteral route of administration for antimicrobials
  • is palatable and available in a suitable formulation (eg a paediatric formulation for children).

Antibiotics used for the treatment of spinal epidural abscess do not have to penetrate the cerebrospinal fluid (CSF). Seek expert advice.