Ultrasound-guided brain abscess aspiration in neonates

Converting emergency pilonidal abscess into an elective procedure

BACKGROUND

Improvements in outcome after surgery for elective pilonidal sinus disease have yet to be matched for those presenting with acute disease. Traditional approaches to the management of acute pilonidal abscess have been associated with slow healing and significant loss of working time.

OBJECTIVE

The aim of this study was to report our approach in which a temporizing intervention allows subsequent definitive treatment with low morbidity.

DESIGN

This article presents a prospective cohort study.

SETTING

This study was performed in acute admissions to the Surgical Unit in York Teaching Hospital.

PATIENTS

Patients presenting with acute pilonidal abscess, not septic, immune-compromised, or diabetic, and without skin necrosis, underwent aspiration on the surgical ward.

INTERVENTION

Aspiration of pilonidal abscess under local anesthetic was performed with the use of a wide-bore needle. The abscess cavity was drained to dryness, samples were sent to the laboratory for microbiology, and empirical oral antibiotics were commenced, covering anaerobes and aerobes. Review was arranged for within 7 days to plan elective excision and primary closure of the underlying pilonidal sinus.

MAIN OUTCOME MEASURES

The primary outcomes measured were the number of days required to return to normal activities, response to treatment, and any residual inflammation.

RESULTS

Fifty-six patients were referred with acute pilonidal abscess. Forty patients met the criteria for aspiration and empirical antibiotic treatment. All were allowed to go home the same day and were reviewed within a median of 5 days. Thirty-eight (38/40) patients demonstrated complete resolution of acute inflammation and were back to normal activities the following day. Fifteen patients subsequently underwent day-case excision and primary closure at a median of 9 weeks. Another 13 are awaiting surgery, and 10 patients have declined further treatment. Two (2/40) patients did not respond, one of whom did not receive the appropriate antibiotics. Both were managed with incision and drainage.

CONCLUSIONS

Aspiration and antibiotic management of pilonidal abscess is effective in 95% of acute cases in preventing the need for emergent laying open and allows for subsequent elective surgery.

Klebsiella pneumoniae brain abscess in neonates: a report of 2 cases

Brain abscesses are uncommon in neonates. Klebsiella pneumoniae is a very uncommon microbial agent to cause brain abscess. We report 2 infants with Klebsiella pneumoniae sepsis who developed brain abscesses. One infant was a premature neonate who required mechanical ventilation for respiratory distress syndrome and subsequently developed nosocomial sepsis and brain abscess without evidence of preceding meningitis. Another infant was a full-term neonate without risk factors for sepsis who developed seizures on the sixth postnatal day and was found to have meningitis and brain abscess. Both infants had Klebsiella pneumoniae septicemia with multiple relatively large brain abscesses that responded poorly to antimicrobial agents. These infants were managed with transfontanel drainage and prolonged courses of antimicrobial agents. Key message of this report is that Klebsiella pneumoniae brain abscess may occur in the absence of meningitis and even in the absence of any identifiable risk factors.

Brain abscess in infants and children

Forty-four consecutive patients with brain abscesses, aged between 1 month and 16 years, were reviewed. The cause of abscess was meningitis in 36% of the cases, otitis in 27%, head injury in 16%, congenital heart disease in 9%, other in 5%, and undetected in 5%. Thirty patients had a single abscess and 12 had multiple abscesses. Multiloculated abscess was present in 2. Total excision was accomplished in 22 patients. Three patients underwent needle aspiration. Drainage of the abscess was performed in 13. Secondary excision was needed in 5 patients. One patient was treated nonsurgically. Streptococci, staphylococci and Proteus mirabilis were the microorganisms recovered in cultures. Overall mortality was 20% (9 patients). Mortality was significantly higher in patients under 2 years of age than in those older. Of 15 patients who were comatose at the time of admission, 6 died. Etiology, diagnostic method, and treatment modalities were not found to be significant factors in terms of predicting mortality.

Ultrasound-guided aspiration of a neonatal brain abscess

The authors successfully treated a Serratia marcescens brain abscess in the right parieto-occipital region of a newborn infant born at 27 weeks' gestation and weighing 800 g. Bedside ultrasound-guided aspiration techniques and local anesthesia were used to treat the abscess.