Choice of antibiotics

In the immunocompetent patient, empirical treatment should be with a combination of a third generation cephalosporin (for example, cefotaxime) and metronidazole.150 Vancomycin is added to this regimen if staphylococci are suspected. Treatment should be given for no less than six weeks but must be determined for each case by clinical response and improvement of CT scan appearances. In the immunosuppressed the choice of treatment will depend on the immune defect, as outlined above. For neutropenic patients and those post transplantation, empirical therapy should include amphotericin B because of the high frequency of fungal infections that occur. In HIV positive patients with multiple lesions, pyrimethamine and sulfadiazine are used to treat toxoplasmosis. If there is not a rapid clinical and radiological response then other pathologies need to be considered.

Dexamethasone is commonly used to treat cerebral oedema and, in practice, the benefit obtained in reducing intracranial pressure outweighs the potential hazard of diminishing the host inflammatory response. The risk of developing epileptic seizures is not insubstantial and prophylactic anticonvulsants are recommended. Mortality is about 25-30% and another third of individuals will have long-term sequelae.

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