Q J Med 2002; 95:501–509

Original papers
QJM
Bacterial brain abscess: microbiological features,
epidemiological trends and therapeutic outcomes

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C.-H. LU 1 , W.-N. CHANG 1 , Y.-C. LIN 2 , N.-W. TSAI 1 , P.-C. LILIANG 2 , T.-M. SU 2 ,
C.-S. RAU 2 , Y.-D. TSAI 2 , C.-L. LIANG 2 , C.-J. CHANG 3 , P.-Y. LEE 4 , H.-W. CHANG 5
and J.-J. WU 6
From the Departments of 1Neurology, 2Neurosurgery, 3Pediatric Neurology, and 4Pharmacy,
Chang Gung Memorial Hospital-Kaohsiung, Kaohsiung, 5Department of Biological Science,
National Sun Yat-Sen University, and 6Department of Medical Technology, National Cheng
Kung University Medical College, Tainan, Taiwan

Received 14 February 2002 and in revised form 22 April 2002

Summary
Background: Despite the advent of modern neuro-
surgical techniques, new antibiotics, and powerful
imaging technologies, brain abscess remains a
potentially fatal central nervous system infection.
Aim: To determine the epidemiological trends,
prognostic factors, and outcomes of bacterial brain
abscess, to improve the therapeutic strategy for this
disease.
Design: Retrospective hospital-based epidemiology
study.
Methods: Over a period of 15 years (1986–2000),
123 patients were retrospectively identified as
having brain abscesses at Kaohsiung Chang Gung
Memorial Hospital. To compare changes over time,
the appearance of disease among our patients was
divided into two time periods: 1986–1993 and
1994–2000.
Results: The prevalence rate of brain abscesses
caused by Gram-negative organisms significantly
increased in the second study period. Viridans
streptococci and Klebsiella pneumoniae were the
two prevalent pathogens associated with haemato-
genous spread. Metastatic septic abscess, a devas-
tating complication of K. pneumoniae septicaemia,
frequently occurs in diabetic patients, with a high
mortality rate. Viridans streptococci were the
most prevalent pathogens from infection in para-
nasal sinusitis, but no fatality occurred. In recent
years, head trauma and/or post-neurosurgical states
have become important predisposing factors,
and nosocomial infections also play an important
role.
Discussion: Despite the availability of new anti-
biotics and the development of better neurosurgical
techniques, therapeutic outcomes of brain abscess
showed no significant change when comparing the
two study periods, and only the presence of septic
shock influenced outcome.

Introduction
Despite the advent of modern neurosurgical tech- fatal central nervous system (CNS) infection.1–4 In
niques, new antibiotics, and new powerful imaging 1973, Kao et al.5 reported the clinical features of
technologies, brain abscess remains a potentially 26 cases of brain abscess with surgical intervention;

Address correspondence to Dr W.-N. Chang, Department of Neurology, Chang Gung Memorial Hospital, 123 Ta Pei
Road, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan. e-mail: chlu99@ms44.url.com.tw
ß Association of Physicians 2002
502 C.-H. Lu et al.
however, a large series study of brain abscess in
Taiwan is still lacking. A hospital-based study
provides accurate information about localization
of brain abscess, predisposing factors, clinical
features, the prevalence rate of implicated bacterial
pathogens, and causes of fatality. In this study,
we investigated differences between nosocomial
and community-acquired infections, predisposing
factors, clinical and neuroimaging findings, com-
plications, and therapeutic outcomes, in order
to improve the therapeutic strategies for this
potentially fatal disease.
Methods
Over a period of 15 years (January 1986 to
December 2000), 123 patients were retrospectively
identified as having brain abscesses at Kaohsiung
Chang Gung Memorial Hospital. The largest med-
ical centre in southern Taiwan, this facility is a
2482-bed acute-care teaching hospital, which
provides both primary and tertiary referral care
services. Southern Taiwan consists of two cities and
three counties (Kaohsiung Municipality and Hsien,
Tainan City and Hsien, and Pingtung Hsien) with
a population of approximately 5 441 000 as of
October 1998.6 The annual population increase
for Taiwan has been reported to be 7.52%.6 To
compare changes over time, the appearance of
disease among our patients was divided into two
time periods: the first time period was 8 years
(January 1986–December 1993) and the was
7 years (January 1994–December 2000).
Criteria of bacterial brain abscess for inclusion
were: (i) characteristic computerized tomography
(CT) and/or magnetic resonance imaging (MRI)
findings; (ii) evidence of brain abscess seen during
surgery or histopathological examination; and (iii)
classical clinical manifestations including head-
ache, fever, localized neurological signs and/or
consciousness disturbance.7–9 All materials from
bacterial brain abscesses were cultured for aerobic
and anaerobic bacteria, mycobacteria, and fungi.
Aerobic culture media included blood, chocolate,
EMB, CNA media, and thioglycolate broths.
Anaerobic cultures were processed in Brucellae
agar plate, BBE/PEA media, and thioglycolate
broths. BHI agar, mycobiotic media, SDA media,
and SCG media were used for fungal isolation.
Lowenstein-Jensen media and middle 7H11 media
were used for mycobacterial isolation. Organisms
were identified by API (Analytab Products),
RapID-ANA II identification system (Innovative Diag-
nostic Systems), and ID 32 C (VITEK, bioMérieux
Vitex). Patients were considered to have mixed
infections if at least two bacterial organisms
were isolated from the initial cultures. Patients
who were initially treated at other hospitals but
subsequently transferred to our hospital for further
therapy were also included in this study, with initial
clinical data collected at those hospitals used for
analysis.
Brain abscesses were defined as nosocomial
according to the 1988 guidelines of the Centers
for Disease Control.7 Brain abscesses related to
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head trauma with skull fracture or neurosurgical
procedures, were classified as post-neurosurgical.
Other patients who presented with no distinctive
characteristics, and/or who had not undergone
invasive procedures, were classified as having the
spontaneous form. Patients with evidence of brain
abscesses not due to bacterial pathogens were
excluded from this study.
The mental status for patients was classified into
two groups: (i) clear consciousness; and (ii) inatten-
tion, confusion, clouded consciousness, stupor, or
coma. Surgical intervention and/or antibiotic ther-
apy were the mainstays of our treatment. Antibiotic
susceptibility was determined using the Kirby-Bauer
disc diffusion method (Mueller-Hinton II agars;
Becton Dickinson). Appropriate antimicrobial
therapy was defined as the administration of one
or more antimicrobial agents, which demonstrated
effectiveness against bacterial pathogens, as deter-
mined from susceptibility tests, and which were
capable of passing through the blood-brain barrier
in adequate amounts. Surgical treatment consisted
of either aspiration or excision of the abscess.
Aspiration was used to aspirate the content of the
abscess with a ventricular catheter via a burr hole
or small craniotomy, which left the capsule alone.
Craniotomy and resection of the abscess was
defined as evacuation. In our institution, those
patients presenting in good neurological condition
with a well-formed abscess in the right hemisphere
underwent evacuation, whereas those presenting
significant surgical risks or those with an abscess
that was deep-seated or in the left hemisphere
underwent aspiration. Recovery was evaluated
3 months after patient discharge.
Data, including initial clinical manifestations,
acquisition of infection, type of infection, numbers
of abscesses, various treatment regimens, and fatal-
ities in the two study periods, were analysed using
the x2 test or Fisher’s exact test. Data for age, and
interval between onset and diagnosis between
fatal and non-fatal groups were compared using
Student’s t-test. Stepwise logistic regression was
used to evaluate the relationship between clinical
 Bacterial brain abscess
factors and the mortality rate adjusting for other
potential confounding factors. All analyses were
conducted using SAS (1990).10
Results
The 123 patients included 92 males (mean age
43 years; range 1 month–80 years) and 31 females
(mean age 41 years; range 2 months–73 years)
(Figure 1). Of these 123 patients, 103 had community-
acquired infections, while the other 20 were
diagnosed with nosocomial infections. Sixty-nine
cases appeared in the first time period (January
1986–December 1993), with the other 54 in the
second time period (January 1994–December 2000)
(Table 1). The ratios of community-acquired to
nosocomial meningitis for these two time periods
were 58:11 and 44:10, respectively.
Associations for portal of entry and causative
pathogens are listed in Table 2. Portal of entry for
infection in 94 culture-positive brain abscesses
included haematogenous spread (n = 32), postneuro-
surgical states (n = 17), contiguous infection from
parameningeal foci such as an otogenic origin
(n = 13), paranasal sinusitis (n = 9), and unknown
(n = 24). In this study, Klebsiella pneumoniae and
viridans streptococci were the two most prevalent
pathogens associated with haematogenous spread,
accounting for 52% (15/29) of the episodes.
Staphylococcus aureus, K. pneumoniae, and viridans
streptococci were the three common pathogens
in postneurosurgical states, accounting for 47%
(7/15) of the episodes. Viridans streptococci were
the most prevalent pathogens from paranasal sinusi-
tis infections, while Proteus species were the
common pathogens of otogenic origin, in brain
abscesses with polymicrobial infection. The mean
interval between onset of symptoms to detection
of brain abscess was 21 days (range 1–700 days).
Figure 1. Age distribution of patients with brain abscess.
503
In the first study period, 58% (40/69) of cases
involved a single pathogen, with viridans strepto-
cocci being the most prevalent (23%), followed
by Bacteroides species (18%), S. aureus (10%), and
Corynebacterium species (10%). Fourteen percent
(10/69) of patients had mixed infections, and
26% (18/69) of patients had a negative culture. In
the second study interval, 70% (38/54) of cases
were infected by a single pathogen, with viridans
streptococci again the most prevalent (29%),
followed by K. pneumoniae (26%). Eleven percent
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(6/54) of patients had mixed infections, and 20%
(11/54) of patients had a negative culture.
Clinical manifestations of these 123 patients are
listed in Table 3. Fever was found in 71 patients
and headache in 68. Forty-nine patients were
admitted with disturbed consciousness. Twenty-
one patients suffered septic shock, 13 of whom
subsequently died. Seizures and/or status epilepti-
cus occurred in 23 patients, of whom five died.
Concomitant bacterial meningitis was found in 29
patients. Of these 29, 24 had community-acquired
infections and five had acquired the infections
nosocomially. Four of the five nosocomially-
infected patients had undergone neurosurgical
procedures as the underlying condition; the other
had had a stroke. Of these 29 cases with con-
comitant bacterial meningitis, five were identified
as K. pneumoniae infection and revealed multiple
septic abscesses on further examination, including
liver abscess, renal abscess, lung abscess, para-
spinal abscess, endophthalmitis, pyomyositis, purulent
pericarditis, and septic arthritis. All five of these
patients were diabetic. Other clinical manifes-
tations in these 123 cases included hemiparesis,
stiff neck, facial palsy, hemiparaesthesia, and
disturbance of speech and vision.
The locations of brain abscesses of these 123
cases were supratentorial in 118 cases and infra-
tentorial in five (Table 4). In total, 99 (80.5%) had a
single brain abscess and 24 (19.5%) had multiple
brain abscesses. The most common sites for brain
abscess were the frontal lobe (33%), followed by
the temporal lobe (20%) and temporo-parietal lobe
(10%). The left hemisphere was involved more than
the right with 63 on the left, 47 on the right, two on
the midline, six bilaterally on both hemispheres,
and five on the infratentorial area.
Antimicrobial therapy, with or without surgical
intervention (aspiration or total excision), was the
cornerstone of treatment in these 123 patients.
Seventeen patients received antimicrobial therapy
alone, four of whom had multiple pyogenic brain
abscesses; the other 13 were associated with
poor systemic conditions. Penicillin G with chlor-
amphenicol was the mainstay of initial empiric
 504

Table 1 Causative organisms, January 1986 through December 2000

Organisms Jan 1986–Dec 1993 (n = 69) Jan 1994–Dec 2000 (n = 54) Total Total deaths
n = 123 n = 21
Community Nosocomial Deaths Community Nosocomial Deaths
n = 58 n = 11* n = 13 n = 44 n = 10** n=8

Gram-negative bacilli (n = 27)

Klebsiella pneumoniae 2 1 2 7 3 2 13 4
Pseudomonas aeruginosa 1 0 0 1 1 1 3 1
Escherichia coli 1 0 1 2 0 0 3 1
Salmonella spp. 0 1 0 1 0 0 2 0
Proteus spp. 0 1 0 1 0 0 2 0
Enterobacter spp. 0 1 0 0 0 0 1 0
Klebsiella oxytoca 0 0 0 1 0 0 1 0
Vibrio cholerae non-O1 1 0 1 0 0 0 1 1
Pasteurella spp. 0 0 0 1 0 0 1 0
Streptococcus species (n = 21)
Viridans streptococci 8 1 0 10 1 0 20 0
non-A, non-B, and non-D streptococci 0 0 0 1 0 0 1 0
C.-H. Lu et al.

Staphylococcus species (n = 9)
Staphylococcus aureus 3 1 2 1 1 0 6 2
Coagulase-negative Staphylococcus 1 0 1 2 0 1 3 2
Corynebacterium spp. (n = 4) 4 0 1 0 0 0 4 1
Anaerobes (n = 17)
Bacteroides spp. 7 0 2 0 0 0 7 2
Fusobacterium spp. 1 1 0 1 0 0 3 0
Peptostreptococcus spp. 0 0 0 1 0 0 1 0
Peptococcus spp. 3 0 1 0 0 0 3 1
Propionibacterium spp. 2 0 0 1 0 0 3 0
Mixed bacterial pathogens (n = 16) 8 2 0 4 2 2 16 2
Negative culture (n = 29) 16 2 2 9 2 2 29 4

*All eleven patients contracted the infection after trauma or neurosurgical procedures. **Except for two patients with K. pneumoniae infection, all the others contracted the
infection after trauma or neurosurgical procedures.

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 Bacterial brain abscess 505

Table 2 Relation between predisposing factors and causative pathogens

Organisms Haematogenous Postneurosurgical Contiguous infection Unknown

spread states***
Otogenic Paranasal
infection sinusitis

Aerobic Gram-negative bacilli

Klebsiella pneumoniae 9* (3) 2 1 0 1 (1)
Pseudomonas aeruginosa 0 1 (1) 0 0 2
Escherichia coli 2 (1) 0 0 0 1
Salmonella spp. 1 1 0 0 0

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Proteus spp. 0 1 1 0 0
Enterobacter spp. 0 1 0 0 0
Klebsiella oxytoca 0 0 1 0 0
Vibrio cholerae non-O1 1(1) 0 0 0 0
Pasteurella spp. 0 0 0 0 1
Streptococcus spp.
Viridans streptococci 6** 2 0 6 6
non-A, non-B, and non-D streptococci 1 0 0 0 0
Staphylococcus spp.
Staphylococcus aureus 1 (1) 3 0 0 2
Coagulase-negative staphylococci 2 (1) 0 0 0 1 (1)
Corynebacterium spp. 2 (1) 0 0 0 2
Anaerobes
Bacteroides spp. 1 1 2 (1) 1 2 (1)
Fusobacterium 1 1 1 0 0
Peptostreptococcus spp. 1 0 0 0 0
Peptococcus spp. 1 0 1 0 1 (1)
Propionibacterium spp. 0 0 0 2 1
Mixed bacterial pathogens 31 (1) 42 53 (1) 0 44
Negative culture 0 2 5 (2) 2 20 (2)

Deaths are shown as figures in parentheses. *Seven of the nine had diabetes mellitus as the underlying disease. **Of these
six, five had heart diseases, including infectious endocarditis (1), tetralogy of Fallot (2), Ebstein’s anomaly (1) and atrial
septal defect (1). ***Included craniotomy due to head trauma (6), intracerebral or subdural haematoma (4), brain tumour (4),
ventriculoperitoneal shunt for hydrocephalus (1). 1Bacteroides melaninogenicus, non-A, non-B, and non-D streptococci;
viridans streptococci, Pseudomonas species; Peptostreptococcus, Bacteroides melaninogenicus. 2Proteus mirabilis,
Enterobacter cloacae; Staphylococcus aureus, viridans streptococci; Proteus mirabilis, Escherichia coli, Serratia
marcescens; Peptostreptococcus, Bacteroides fragilis. 3Proteus vulgaris, Klebsiella oxytoca; Bacteroides fragilis, Proteus
mirabilis, Pseudomonas spp., Enterococcus spp., Group D streptococci; Bacteroides spp; Escherichia coli, Proteus mirabilis,
Corynebacterium, Bacteroides spp.; Peptococcus, Veillonella spp.; Enterococcus, Staphylococcus aureus, non-A, non-B,
and non-D streptococci; viridans streptococci, Klebsiella pneumoniae. 4Bacillus, Fusobacterium nucleatum; Prevotella
intermedia, Fusobacterium nucleatum, viridans streptococci; Bacteroides fragilis, Proteus mirabilis; viridans streptococci,
Peptococcus.

antimicrobial treatment of bacterial brain abscess
unless Staphylococcus or Gram-negative bacilli
were more likely to be the responsible pathogens.
The choice of final antibiotics was guided by the
final culture results. With this regimen of therapy,
12 patients experienced recurrence of brain
abscesses, and they received repeated aspiration
and/or total excision of brain abscesses. In total,
102/123 patients survived. Mortality rates for the
first and second study periods were 19% and 15%,
respectively (Figure 2). Nine of 67 patients who
received both antimicrobial therapy and total
excision died. Six of 33 patients who received
both antimicrobial therapy and aspiration died. All
six patients who received antimicrobial therapy and
aspiration with subsequent total excision survived,
while there were six fatalities among the 17 patients
who received antimicrobial therapy alone.
Mortality rates of patients by group of causative
organism were as follows: Gram-negative bacilli,
27% (7/26); Streptococcus spp., 0% (0/21);
Staphylococcus spp., 33% (3/9); Corynebacterium
spp., 25% (1/4); anaerobic pathogens, 17% (3/18);
mixed bacterial species, 13% (2/16); and negative
cultures, 14% (4/29) (Table 1). Of the 21 patients
who died, 13 had fulminant clinical courses and
506 C.-H. Lu et al.

Table 3 Clinical manifestations

Community-acquired Nosocomial Total (n = 123)

(n = 102) (d = 20) (n = 21) (d = 1) (d = 21)

Fever/chills 60 11 71
Headache 63 5 68
Disturbed consciousness 44 15 59
Hemiparesis 44 10 54
Nausea/vomiting 35 4 39
Stiff neck 33 3 36
Speech disturbance 22 3 25

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Seizure 18 5 23
Septic shock 20 1 21
Visual disturbance 17 1 18
Facial palsy 8 1 9
Hemiparaesthesia 7 1 8

d, deaths.

Table 4 Localization of brain abscesses deterioration of systemic conditions, three had

intracerebral haemorrhage after surgical interven-
Localization Number of cases tions, and four had brain swelling with subsequent
(n = 123) (%) herniation. Among the 102 survivors, 64 resumed
normal lives or had mild mental abnormalities, 27
Single site
had focal neurological deficits with moderate
Frontal lobe 33
Temporal lobe 20 disability, and 11 had severe disability or were in
Temporo-parietal area 10 a persistent vegetative state.
Basal ganglion 8 The potential prognostic factors of these 123
Occipital lobe 6 patients are listed in Table 5. According to the
Parieto-occipital area 6 statistical analysis, only the presence of septic shock
Fronto-parietal area 5 (p-0.001) had a significant influence on therapeu-
Parietal lobe 4 tic outcomes. Variables, including age at infection,
Cerebellum 4 sex, acquisition of infection, type of infection, type
Cerebellopontine angle 1 of treatment, headache, fever, septic shock, seizure,
Third ventricle 1
concomitant meningitis, mental status, and the
Intrasellar area 1
interval between onset and diagnosis, were used
Total 99 (80.5%)
Multiple sites 24 (19.5%) in the stepwise logistic regression, and the presence
of septic shock (p = 0.0001) was the only factor
predictive of mortality.

Figure 2. Numbers of fatal and non-fatal cases of
bacterial brain abscess, distributed over 15 years.
Discussion
The causative pathogens of bacterial brain abscess
vary with time period, geographic distribution, age,
underlying medical and/or surgical conditions, and
mode of infection.1–5 The relative frequency of
mixed bacterial infections and limitations of anae-
robic culture techniques also influence the patho-
gen prevalence in different studies.1–14 A study
from China reported that Gram-negative bacilli,
with Proteus, Enterobacter and Alcaligenes species
being common, accounted for 21% (82/400) of the
implicated pathogens of brain abscess from 1952
to 1972.14 In one early study of brain abscess from
Taiwan, Gram-negative bacilli, Staphylococcus
 Bacterial brain abscess 507

Table 5 Prognostic factors

Prognostic factor Patients Dead Alive p OR 95%CI Statistical test

(1) Age at infection (mean, years)

All 49.0 40.8 0.079 Student’s t
(2) Sex
Male 92 16 76 0.875 1.10 0.37–3.28 x2
Female 31 5 26
(3) Acquisition of infection
Community 102 20 82 0.121 4.88 0.62–38.54 Fisher’s exact
Nosocomial 21 1 20

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(4) Type of infection
Spontaneous meningitis 104 20 84 0.192 4.29 0.54–34.03 Fisher’s exact
Postneurosurgical meningitis 19 1 18
(5) Types of treatment
Excision and antimicrobial 66 9 57*** 0.165 2.15 0.11–41.33 Fisher’s exact
Aspiration and antimicrobial 34 6 28 2.97 0.15–59.55
Antimicrobial alone 17 6 11 7.35 0.35–152.53
Aspiration then excision plus 6 0 6
antibiotics
(6) Clinical manifestations
Headache
Yes 68 10 58 0.477 0.69 0.27–1.77 x2
No 55 11 44
Fever
Yes 71 15 56 0.163 2.05 0.74–5.72 x2
No 52 6 46
Septic shock
Yes 21 13 8 -0.001** 19.10 6.11–59.63 Fisher’s exact
No 102 8 94
Seizure
Yes 23 5 18 0.542 1.46 0.47–4.50 Fisher’s exact
No 100 16 84
Focal neurological deficits*
Yes 78 14 64 0.734 1.19 0.44–3.20 x2
No 45 7 38
Concomitant meningitis
Yes 29 3 26 0.40 0.49 0.13–1.79 x2
No 94 18 76
Mental status
Group I 64 11 53 0.972 1.02 0.40–2.60 x2
Group II 59 10 49
(7) Interval between onset and diagnosis (mean, days)
All 10.6 23.2 0.11 Student’s t

*Focal neurological deficits included hemiparesis, facial palsy, hemiparesthesia, and disturbance of speech and vision.
**Statistically significant. ***Relative to aspiration then excision plus antibiotics treatment.

species, and Streptococcus species accounted for
40% (10/25) of the episodes,5 and these three
groups of pathogens also accounted for 46%
(56/123) of the pathogens implicated in this study.
Of the Streptococcus species, viridans streptococci
were the most frequently found, at 13% (9/69)
and 22% (12/54) of the implicated pathogens in
the first and second study time periods, respec-
tively. Although there was a change in the relative
frequency of pathogens, viridans streptococci
remained the most prevalent pathogens in both
time periods. Among the Gram-negative bacilli,
K. pneumoniae, E. coli, P. aeruginosa, and other
rare Gram-negative organisms accounted for more
than 21% of implicated pathogens. There was a
significantly increased prevalence of Gram-negative
organisms of from 13% (9/69) in the first to 31%
(17/54) in the second time period.
This study shows that clinical presentations and
underlying disorders vary greatly in brain abscesses
508 C.-H. Lu et al.
due to different species. K. pneumoniae was the
most prevalent pathogen associated with haemato-
genous spread or postneurosurgical states. Multiple
metastatic septic abscesses were common in
patients with brain abscess due to K. pneumoniae.
Although the reason is unknown, this association
of Klebsiella infection with metastatic abscesses
has been noted in other reports from Taiwan.15–17
Of the brain abscesses caused by Streptococcus
species, viridans streptococci, the most prevalent
members of the flora in the upper respiratory tract,
gastrointestinal tract, and female genital tract,
accounted for 95% of strains. This study also
shows that viridans streptococci are the prevalent
pathogens with haematogenous spread secondary
to cardiogenic origin or from infection of paranasal
sinusitis; this finding is consistent with those of
other reports.18,19 In this study, no deaths due
to viridans streptococci occurred, which may well
be due to the low virulence of viridans strepto-
cocci.18,20 In the brain abscesses of otogenic origin,
Proteus species were the most commonly impli-
cated pathogens among the brain abscesses with
polymicrobial infection, and this phenomenon was
also noted in other studies.13,21 This study also
showed that S. aureus, viridans streptococci, and K.
pneumoniae were the most prevalent pathogens in
patients with post-neurosurgical states.
Regarding the portal of entry, brain abscess is
almost always secondary to a focus of suppuration
elsewhere in the body, and may develop either
by a contiguous focus of infection, head trauma,
or haematogenous spread from a distant focus.
Although head trauma or neurosurgical procedures
were once unusual as causes of brain abscesses,
they were important in this study. As a previous
report12 demonstrated and our study confirms, when
haematogenous spread is the source of the brain
abscess, this infection is frequently community-
acquired, and is commonly associated with under-
lying diseases and with more fulminant courses,
as evidenced by higher rates for shock and death.
By contrast, postneurosurgical causes and a
contiguous focus of infection are associated with a
favourable outcome.
In our 123 cases with brain abscesses; fever,
headache, altered consciousness, and hemiparesis
were the most common manifestations, occurring
in 58%, 55%, 50%, and 44% of our patients,
respectively. The presence of focal neurological
findings (e.g. hemiparesis, hemisensory deficits, and
aphasia) depends on the location of the abscess,
and these signs were seen in approximately 63%
(78/123) of our cases, while 37% (45/123) had
no localized signs. The presence of septic shock
significantly influenced the outcome of our patients.
However, the presence of fever, headache, seizure,
and focal neurological signs showed no statistical
significance on the prognosis in our study. The
interval between onset of symptom and signs and
diagnosis was of no statistical significance in our
study, as in a previous study.12
Metastatic abscesses are commonly located in
the parietal, frontal, or temporal lobes,12,14 and
multiple brain abscesses are usually the result
of metastatic spread from remote primary foci,
accounting for 6% to 22% of cases.12,14 In this
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study, the most common cause of brain abscesses
was haematogenous spread, accounting for 26%
(32/123) of the episodes, a figure higher than the
study from China.14 Almost all abscesses were
found in the frontal, temporal, and parietal lobes,
and multiple abscesses were present in 19.5%
(24/123). Although brain abscesses associated with
neurosurgical procedures were once considered
uncommon,2,14 they accounted for 12% of the
episodes in this study. The increasing frequency
of neurosurgical procedures may be due to the
increasing number of neurosurgeons, the improve-
ment of neurosurgical facilities, and the large
number of patients with head injury from motor-
cycle accidents. Unlike the data shown in one study
from China,14 where the majority of the abscesses
were temporal and cerebellar, suggesting otogenic
spread, our patients had more frontal disease.
This may reflect the trend towards better and
more aggressive management of otogenic disorders
between the 1970s and the 1990s.
Treatment of brain abscess requires a combina-
tion of antimicrobials, surgical intervention, and
eradication of primary infected foci. In Taiwan,
initial empirical antibiotics with third-generation
cephalosporins in combination with metronidazole,
should be considered for the majority of abscesses
cases resulting from infection with Gram-negative
bacilli and streptococcal species. Different the-
rapeutic regimens show no significant statistic
differences in prognosis in other reports,12 and
were also of no statistical significance in this
study.
In summary, the clinical presentations, under-
lying conditions and therapeutic outcomes vary
greatly in brain abscesses, according to the different
pathogens. In recent years, head trauma and/or
post-neurosurgical states have become important
predisposing factors of brain abscess, and noso-
comial infections are also important. Despite the
availability of new antibiotics and the development
of better neurosurgical techniques, therapeutic
outcomes of brain abscess have not shown a
statistically significant change, and only the
presence of septic shock is a prognostic factor.
 Bacterial brain abscess
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