Pediatric Intracranial Abscesses in a Tertiary Care Center: Antimicrobial Management, Diagnostic Yield of Molecular Testing and Radiologic Follow-Up

BACKGROUND: Brain abscesses and intracranial empyemas are rare but serious infections associated with substantial morbidity and long-term neurologic sequelae. Microbiologic confirmation is often limited by prior empirical therapy, and the diagnostic yield of real-time polymerase chain reaction in real-world settings remains uncertain. Evidence guiding antimicrobial duration, microbiologic work-up and radiologic follow-up in children is limited. We aimed to describe a pediatric cohort, focusing on management strategies, molecular diagnostics and radiologic follow-up. METHODS: In this single-center study, we reviewed the clinical charts of a tertiary care pediatric hospital in Italy from 2017 to 2025. Children younger than 18 years diagnosed with brain abscess or subdural/epidural empyema were included. Clinical, radiologic, microbiologic, and immunologic treatment and outcome data were collected. Comparisons were performed using the Mann-Whitney U test and Fisher exact test. RESULTS: The study cohort included 26 children (17 brain abscesses, 7 subdural empyemas and 2 epidural empyemas). Pathogens were identified in 21 patients (81%), with 23 isolates. Real-time polymerase chain reaction exclusively detected 43% of isolates (10/23). Half of patients received <6 weeks of intravenous therapy without recurrence, including 35% of brain abscesses. Children undergoing drainage/craniotomy had larger lesions ( P = 0.04) and required longer intravenous treatments than those managed conservatively (42 vs. 20 days, P = 0.022). Radiologic follow-up showed residual findings in most cases (60%). One child died; neurologic sequelae occurred in 15% of cases. CONCLUSIONS: Pediatric intracranial abscesses require intensive multidisciplinary care, with marked heterogeneity in current treatment strategies. Molecular testing substantially enhances diagnostic yield and pathogen identification. Radiologic structural sequelae are common, but their prognostic significance remains unclear. Standardized pediatric protocols and well-designed prospective studies are needed to optimize antimicrobial stewardship, define which candidates may safely receive shorter intravenous courses, and harmonize follow-up imaging.