Recommended intravenous doses of antimicrobial therapy for adults with bacterial brain abscess who have normal renal and hepatic function

Antimicrobial agent	Dose (adult)	Comment
Amikacin	5 mg/kg every 8 hours*	Aminoglycosides are not routinely used for treatment of brain abscess, but may be considered in select cases (eg, multidrug-resistant gram-negative infection when treatment options are limited).
Ampicillin	2 g every 4 hours
Aztreonam	2 g every 6 to 8 hours	Alternative agent generally used for patients with severe beta-lactam allergies.
Cefepime	2 g every 8 hours
Cefotaxime	2 g every 4 to 6 hours
Ceftaroline	600 mg every 8 hours	Alternative therapy in cases of MRSA that are not responding to vancomycin or linezolid; if used, many experts would combine with another agent effective against MRSA.
Ceftazidime	2 g every 8 hours
Ceftriaxone	2 g every 12 hours
Ciprofloxacin	400 mg every 8 to 12 hours	Alternative agent generally used for patients with severe beta-lactam allergies.
Daptomycin	6 to 10 mg/kg every 24 hours	Alternative agent for suspected S. aureus (or proven MRSA) in patients who cannot tolerate vancomycin. Daptomycin has poor central nervous system penetration and is generally not recommended; if used because other alternatives are not available, it should be combined with rifampin therapy.
Gentamicin	1.7 mg/kg every 8 hours*	Aminoglycosides are not routinely used for treatment of brain abscess, but may be considered in select cases (eg, multidrug-resistant gram-negative infection when treatment options are limited).
Linezolid^¶	600 mg every 12 hours	Alternative agent for suspected S. aureus (or proven MRSA) in patients who cannot tolerate vancomycin.
Meropenem	2 g every 8 hours
Metronidazole	7.5 mg/kg (usually 500 mg) every 6 to 8 hours; maximum dose: 4 g/day
Moxifloxacin	400 mg every 24 hours	Alternative agent generally used for patients with severe beta-lactam allergies.
Nafcillin	2 g every 4 hours
Oxacillin	2 g every 4 hours
Penicillin G potassium	4 million units every 4 hours
Rifampin	600 mg every 24 hours^Δ	Rifampin should not be used as monotherapy, but it may be used in combination with other agents to enhance the antimicrobial activity.
Tobramycin	1.7 mg/kg every 8 hours*	Aminoglycosides are not routinely used for treatment of brain abscess but may be considered in select cases (eg, multidrug-resistant gram-negative infection when treatment options are limited).
Trimethoprim-sulfamethoxazole (co-trimoxazole)	5 mg/kg every 8 to 12 hours^◊
Vancomycin	15 to 20 mg/kg every 8 to 12 hours^§

MRSA: methicillin-resistant Staphylococcus aureus; IV: intravenously; AUC: area under the curve.
* The doses are based on ideal body weight or adjusted body weight except in underweight patients. A calculator for ideal body weight and adjusted body weight is available in UpToDate. For gentamicin or tobramycin, dose and interval must be individualized to produce a peak serum concentration of 7 to 10 mcg/mL and trough serum concentration <2 mcg/mL (ideally <1 mcg/mL); for amikacin, target a peak serum concentration of 25 to 40 mcg/mL and trough serum concentration of <8 mcg/mL (ideally <4 mcg/mL). There are insufficient data to suggest dosing using a high-dose extended-interval regimen. On rare occasion (eg, if the abscess has ruptured into the ventricles), intrathecal administration may be warranted. For additional information, refer to the UpToDate topic on aminoglycoside dosing and administration.
¶ Prolonged therapy with linezolid increases the risk of serious toxicity (eg, hematologic toxicity typically occurs when used longer than two weeks). Linezolid may be administered orally instead of IV in select settings (eg, those with poor IV access who have had an appropriate initial response).
Δ Rifampin can be administered orally instead of IV.
◊ Dosage is based on the trimethoprim component. We administer trimethoprim-sulfamethoxazole at a dose of 5 mg/kg (based on the trimethoprim component) IV every 8 hours in patients with normal renal function. However, there are limited data on the preferred dosing interval; in case reports, dosing intervals of every 6 hours or every 12 hours were also used.
§ For treatment of brain abscess due to known or suspected S. aureus, a vancomycin loading dose (20 to 35 mg/kg) is appropriate;^[1,2] within this range, we use a higher dose for critically ill patients. The loading dose is based on actual body weight, rounded to the nearest 250 mg increment (maximum dose: 3 g). The initial maintenance dose and interval may be determined either by nomogram (typically 15 to 20 mg/kg every 8 to 12 hours [maximum single dose: 2 g; maximum daily dose: 4.5 g] for most patients with normal renal function) or by utilizing first-order equations based on estimates of creatinine clearance using the Cockcroft-Gault equation. Subsequent dose and interval adjustments are based on AUC-guided or trough-guided serum concentration monitoring. For treatment of brain abscess due to pathogens other than S. aureus, a loading dose is generally not required. Refer to the UpToDate topic on vancomycin dosing for additional information, including a sample nomogram and discussion of vancomycin monitoring.

References:

Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children: Executive Summary. Clin Infect Dis 2011; 52:285.
Rybak MJ, Le J, Lodise TP, et al. Therapeutic Monitoring of Vancomycin for Serious Methicillin-Resistant Staphylococcus Aureus Infections: A Revised Consensus Guideline and Review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.

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Recommended intravenous doses of antimicrobial therapy for adults with bacterial brain abscess who have normal renal and hepatic function