›Amphotericin B deoxycholate 0.7-1 mg/kg IV daily as alternative
›Indications: Immunocompromise, chronic corticosteroids, candida risk factors
›ID consultation mandatory for antifungal selection
Antibiotic de-escalation and duration
›Culture-directed therapy
›Narrow based on identification and susceptibility
›MSSA: Nafcillin 1.5-2 g IV every 4 hours or cefazolin 2 g IV every 8 hours
›MRSA: Continue vancomycin or transition to daptomycin 6-10 mg/kg IV daily
›Streptococcal species: Penicillin G 3-4 million units IV every 4 hours or ceftriaxone 2 g IV daily
›Gram-negative: Guided by susceptibility (ceftriaxone, cefepime, or ciprofloxacin)
›ID consultation essential for regimen finalization
›Duration of therapy
›Parenteral: Typically 6-8 weeks total
›Individualized to clinical response, organism, and surgical management
›Oral step-down with highly bioavailable agents in selected patients
›Oral step-down criteria
›Clinical improvement after minimum 2 weeks IV therapy
›Reliable highly bioavailable oral agent available (fluoroquinolone, linezolid, trimethoprim-sulfamethoxazole)
›Confirmed adherence and follow-up
›End-of-therapy assessment
›ESR and CRP compared to baseline
›Neurologic exam
›Repeat MRI for MRSA, no drainage, nonoperative management
›Urgent surgical decompression
›Indications
›New or progressive neurologic deficits (most urgent indication)
›Cord compression with threatened spinal cord
›Failed nonoperative management with any clinical worsening
›Timing
›Best neurologic outcomes when surgery within 24-48 hours of neurologic deficit onset
›Any additional delay worsens outcome
›Paralysis >48 hours reduces but does not eliminate chance of recovery
›Surgical approaches
›Laminectomy with decompression
›Standard approach for posterior epidural abscess
›Drainage and debridement of abscess cavity
›Intraoperative cultures mandatory
›Multilevel laminectomy for extensive abscess
›Required when abscess spans >3 vertebral levels
›May require spinal stabilization if instability present
›Catheter-based irrigation
›Minimally invasive option for extensive abscess without major cord compression
›Continuous irrigation and drainage system
›Anterior approach for anterior epidural abscess
›Required when anterior cord compression is dominant
›Higher risk; reserved for selected cases with spine surgery expertise
›Analgesia
›Acetaminophen 500-1000 mg PO/IV every 6 hours
›First-line analgesic; avoid in hepatic failure
›Scheduled rather than PRN for moderate-severe pain
›Opioids
›Short-acting opioids for breakthrough pain
›Avoid in patients at risk of obtundation affecting neurologic monitoring
›Oxycodone 5 mg PO every 4-6 hours as needed for breakthrough
›NSAIDs
›Avoid in renal impairment and anticoagulated patients
›Ibuprofen 400-600 mg PO every 6-8 hours if renal function normal
›Glycemic control
›Target glucose 6-10 mmol/l in hospitalized patients
›Hyperglycemia impairs immune function and wound healing
›Insulin sliding scale or continuous infusion as needed
›Endocrinology consultation for complex diabetic management
›DVT prophylaxis
›Pharmacologic prophylaxis after surgical clearance
›Enoxaparin 40 mg SC daily or unfractionated heparin 5000 units SC TID
›Delay until 24-48 hours post-surgery to reduce hematoma risk
›Mechanical prophylaxis (sequential compression devices)
›Initiate immediately on admission
›Continue until ambulatory