Intracranial Suppurative Infections in Children

BACKGROUND: Intracranial suppurative infections (epidural empyema, subdural empyema and brain abscess) are rare but severe pediatric conditions associated with diagnostic delay, neurological sequelae and heterogeneous management. Evidence guiding optimal antibiotic duration, route of administration and adjunctive corticosteroid use remains limited. METHODS: We conducted a retrospective multicenter study, including children <14 years diagnosed with intracranial suppurative infections between 2015 and 2024 across 6 tertiary hospitals in southern Spain. Clinical, microbiological, treatment and outcome data were extracted from medical records. Descriptive and comparative analyses, including logistic regression, were performed to identify factors associated with outcomes. RESULTS: Seventy-five patients were included (median age 74 months; 61.3% male). Brain abscess was the most frequent diagnosis (44%), followed by subdural (33.3%) and epidural empyema (29.3%). An otorhinolaryngologic source was identified in 83% of children >2 years. Microbiological diagnosis was achieved in 72%; most isolates included Streptococcus species (42.7%). Empirical antibiotic regimens varied widely; vancomycin was used in 69.3% but frequently discontinued after culture results. The antibiotic route was switched to oral in 21 patients (28.8%), with no increased need for repeat surgical intervention or sequelae. Corticosteroids were used in 49.3% of cases. Sequelae occurred in 29.3%, more frequently in infants (<24 months: 45.5% vs. 22.6%, P = 0.048). Neurological deficits at presentation (odds ratio 8.22) and vomiting (odds ratio 3.55) were associated with sequelae. Mortality was 4.0%. CONCLUSIONS: Pediatric intracranial suppurative infections are associated with significant morbidity and marked variability in management across centers. Selected patients may safely transition to oral antibiotics after initial intravenous therapy, although prospective studies are needed. Standardized treatment protocols are required to optimize outcomes and reduce neurological sequelae.