Introduction
Methods
Clarity of the recommendation: Does ChatGPT give a clear response? | Alignment Score (adapted according to Cakir et al. [5]) | Patient risk score | |||
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(a) | Yes, concrete | 1 point | Completely correct (ChatGPT's recommendation matches the ESCMID guideline completely) | (a) | Recommendation presents no patient hazard |
(b) | Yes, but incomplete | 2 points | Correct but inadequate (ChatGPT's recommendation somewhat matches but lacks the full depth/detail of the ESCMID guideline) | (b) | A patient hazard cannot be ruled out |
(c) | No | 3 points | A mix of correct and misleading information (ChatGPT's recommendation diverges significantly but may have some minor overlap with the ESCMID guideline) | (c) | The recommendation poses a high risk of patient harm |
4 points | Completely incorrect (ChatGPT's recommendations directly contradicts the ESCMID guideline) |
Ethics approval
Results
ChatGPT provided mostly clear responses to key questions on brain abscess
ChatGPT (without data) | ChatGPT (with data) | ESCMID guideline | |||||||||||||
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Key question | Recommendation | Grade of evidence | Strength of recommen-dation | Clarity of recommen-dation | Alignment with ESCMID | Patient risk score | Recommendation | Grade of evidence | Strength of recommen-dation | Clarity of recommen-dation | Alignment with ESCMID | Patient risk score | Recommendation | Grade of evidence | Strength of recommendation |
1: What is the preferred brain imaging modality in patients with suspected brain abscess? | Magnetic resonance imaging (MRI) with contrast is the preferred brain imaging modality for patients with suspected brain abscess because it offers superior soft-tissue resolution and can better differentiate abscesses from other intracranial lesions. Computed tomography (CT) with contrast can also detect brain abscesses, but MRI is more sensitive and specific for this purpose. | Low | Strong | b, a, a | 2.0 (2, 2, 2) | a, a, a | Based on the information provided in this chat, the preferred brain imaging modality for patients with suspected brain abscess is CE-SWI (Contrast Enhanced Susceptibility Weighted Imaging). However, it's crucial to examine the original magnitude and phase images carefully due to potential post-processing artifacts. | Observa-tional | Moderate | b, b, c | 3.3 (3, 3, 4) | a, a, a | We strongly recommend brain MRI including DWI/ADC and T1 weighted imaging with and without gadolinium for patients with suspected brain abscess. If MRI is not available, contrast-enhanced CT is recommended. | High | Strong |
2: Should antimicrobials be withheld until aspiration or excision in patients with suspected brain abscess? | No, in patients with suspected brain abscess, empiric antimicrobial therapy should be initiated promptly after obtaining necessary cultures (preferably before administering antibiotics, if possible). Delaying antimicrobial treatment can lead to disease progression and worsened outcomes, while obtaining a sample for culture prior to antibiotic initiation ensures the best chance of identifying the causative organism. | Moderate to low | Strong | b, b, c | 3.3 (4, 3, 3) | b, a, a | Based on the information provided in the chat, most studies suggest that withholding antimicrobials until aspiration or excision in patients with suspected brain abscess might lead to better culture yields. Therefore, it is recommended to consider withholding antimicrobials in such cases to optimize diagnostic accuracy, unless clinically contraindicated. | Moderate to strong | Strong | a, b, c | 1.3 (1, 1, 2) | a, NA, a | We conditionally recommend that antimicrobials are withheld until aspiration or excision of brain abscess in patients without severe disease if neurosurgery can be carried out within reasonable time, preferably within 24 hours of radiological diagnosis. | Low | Conditional |
3: Should molecular-based diagnostics be used in patients with brain abscess? | Molecular-based diagnostics, such as polymerase chain reaction (PCR) and next-generation sequencing, can be useful in identifying causative organisms in brain abscesses, especially when conventional cultures are negative or when atypical pathogens are suspected. Their use can supplement traditional culture methods and provide more comprehensive pathogen identification, particularly in challenging cases. | Moderate to low | Moderate | b, b, a | 1.3 (1, 2, 1) | a, a, a | Molecular-based diagnostics offer rapid and accurate identification of pathogens in patients with brain abscesses and can be especially beneficial when traditional culture methods are inconclusive. However, it's essential to interpret results alongside clinical findings and ensure proper sample collection to avoid contamination. | - | - | b, a, a | 1.7 (3, 1, 1) | a, NA, a | We conditionally recommend the use of molecular-based diagnostics, if available, in patients with negative cultures. | Moderate | Conditional |
4: Should neurosurgical aspiration or excision be used in patients with brain abscess? | Neurosurgical aspiration or excision is indicated in patients with brain abscesses for both diagnostic and therapeutic purposes. Factors favoring surgical intervention include larger abscess size (usually >2.5 cm), location (e.g., in the cerebellum where mass effect is poorly tolerated), failure of medical therapy, or the need for definitive microbiological diagnosis when cultures are negative or unclear. | Moderate to low | Strong | b, b, a | 2.0 (3, 2, 1) | b, a, a | Based on the information provided in this chat, early surgical intervention, either through neurosurgical aspiration or excision, is associated with a reduced risk of treatment failure in patients with brain abscesses, especially in specific conditions. Therefore, neurosurgical intervention is recommended for patients with brain abscesses, considering individual clinical presentations and circumstances. | Moderate | Moderate | b, a, a | 1.7 (2, 2, 1) | a, a, a | We strongly recommend neurosurgical aspiration or excision of brain abscess as soon as possible whenever feasible (excl. toxoplasmosis). | Moderate | Strong |
5: What is the optimal empirical antimicrobial therapy for brain abscess? | The optimal empirical antimicrobial therapy for brain abscess typically targets a combination of aerobic and anaerobic bacteria, including streptococci, staphylococci, and gram-negative bacilli. Commonly used regimens include a third or fourth-generation cephalosporin (e.g., ceftriaxone or cefotaxime) combined with metronidazole; if there's concern for MRSA, vancomycin or linezolid can be added. | Moderate to low | Strong | b, a, a | 2.0 (2, 2, 2) | a, a, a | Based on the provided studies in this chat, the optimal empirical antimicrobial therapy for brain abscess includes a combination of third-generation cephalosporins (such as cefotaxime or ceftriaxone), metronidazole, and vancomycin. This regimen covers a broad spectrum of the commonly implicated pathogens in brain abscesses. | Low | Moderate | a, a, a | 2.0 (2, 2, 2) | a, a, a | We strongly recommend 3rd generation cephalosporin combined with metronidazole for empirical treatment of community-acquired brain abscess in children and adults (Suppl. Table 3). Dosages should be tailored toward adequate abscess and central nervous system penetration (Suppl. Table 10). | Low | Strong |
6: What is the appropriate duration of antimicrobial therapy for bacterial brain abscess? | The appropriate duration of antimicrobial therapy for bacterial brain abscess typically ranges from 6 to 8 weeks. The exact duration may vary based on the causative organism, the clinical response to treatment, and whether surgical intervention was undertaken, with some cases requiring a longer duration of therapy based on individual circumstances. | Moderate to low | Strong | b, a, a | 1.7 (2, 2, 1) | a, a, a | The appropriate duration of antimicrobial therapy for bacterial brain abscess, based on the provided information, is intravenous administration for about 4 weeks, followed by 12 weeks of oral medication. This recommendation is derived from the study's strategy, which achieved high cure rates with minimal treatment-related adverse events. | – | – | b, a, a | 3.7 (4, 4, 3) | b, b, a | We conditionally recommend a total duration of 6-8 weeks of intravenous antimicrobials for aspirated or conservatively treated brain abscesses. Based on expert opinion, a shorter duration of four weeks may be considered in patients treated with excision of brain abscess. | Low | Conditional |
7: Should early transition to oral antimicrobials be used in treatment of patients with bacterial brain abscess? | Early transition to oral antimicrobials in the treatment of bacterial brain abscess can be considered in select patients who have had a good clinical response to intravenous therapy and when a suitable oral agent with good CNS penetration is available. However, the decision should be individualized based on the causative organism, abscess size, clinical progress, and availability of oral agents with adequate bioavailability and brain penetration. | Moderate to low | Moderate | b, b, b | 2.0 (2, 2, NA) | a, a, a | Based on the information provided, an early switch to oral antibiotics during the first 14 days of treatment for brain abscesses seems to be associated with favorable outcomes in selected patients. However, due to the limitations of the studies, including their retrospective nature, it's recommended to proceed with caution, and more robust, prospective research is needed to confirm these findings. | Moderate | Conditional | b, b, b | 4.0 (4, 4, NA) | b, b, a | No recommendation. For early transition to oral antimicrobials in patients with brain abscess, there is insufficient evidence at the time of writing to provide a recommendation. | - | - |
8: Should consolidation therapy with oral antimicrobials after ≥6 weeks of IV antimicrobials be used to reduce risks of relapse or recurrence? | Consolidation therapy with oral antimicrobials after ≥6 weeks of IV antimicrobials for bacterial brain abscess can be considered, especially in cases where there are concerns about incomplete resolution or potential for relapse. However, the need and duration for such consolidation therapy should be individualized based on clinical and radiological progress, the causative organism, and the risk factors associated with the patient. | Moderate to low | Moderate | b, b, a | 2.3 (3, 2, 2) | a, a, a | Based on the provided data, the study does not explicitly mention or provide evidence regarding the efficacy of consolidation therapy with oral antimicrobials after ≥6 weeks of IV antimicrobials for the prevention of relapse or recurrence in pediatric brain abscess patients. Therefore, a clear recommendation cannot be made based on the given information. | Very low | Conditional | a, c, a | 3.0 (3, 3, 3) | a, a, a | Based on expert opinion, we conditionally do not recommend oral consolidation treatment after ≥6 weeks of IV antimicrobials for brain abscess (excl. permanent neuroanatomical defects, tuberculosis, nocardiosis, toxoplasmosis, and fungal brain abscess). | Very low | Conditional |
9: Should dexamethasone be used to treat severe symptoms due to perifocal oedema in patients with brain abscess? | Yes, dexamethasone can be used to treat severe symptoms due to perifocal edema in patients with brain abscess. It can help reduce cerebral edema and alleviate increased intracranial pressure, but its use should be short-term and typically tapered as symptoms improve to minimize potential side effects. | Moderate to low | Strong | a, a, a | 1.3 (1, 2, 1) | a*, a, a | Based on the provided data, dexamethasone shows a potential benefit in reducing the mortality and surgical intervention rate in patients with brain abscess experiencing severe symptoms due to perifocal oedema. However, given the observational nature of the data, the recommendation should be approached with caution, and further randomized controlled trials are needed to confirm its efficacy. | Low | Weak | b, b, b | 2.7 (3, 3, 2) | a, a, a | In the absence of convincing clinical data of harm related to adjunctive corticosteroid treatment, we strongly recommend use of corticosteroids for management of severe symptoms due to perifocal oedema or impending hernation in patients with brain abscess. | Low | Strong |
10: Should primary prophylaxis with antiepileptic treatment be used to reduce risks of seizures during admission and subsequent epilepsy? | As of my last update in September 2021, primary prophylaxis with antiepileptic drugs (AEDs) for patients with brain abscess to reduce the risk of seizures during admission and prevent subsequent epilepsy remains controversial. Some guidelines recommend short-term prophylaxis during the acute phase, especially if there are risk factors for seizures, while others suggest it may not be necessary for all patients and emphasize the potential side effects and drug interactions associated with AEDs. | Moderate to low | Moderate | c, c, c | 3.0 (3, 3, 3) | a, a, a | Based on the information provided, the text does not directly address the use of primary prophylaxis with antiepileptic treatment for patients with brain abscesses. Therefore, given the available data, it is not possible to make a definitive recommendation on the use of antiepileptics for primary prophylaxis in this patient population. | – | – | a, a, a | 2.7 (2, 2, 4) | a, a, a | Based on expert opinion, we conditionally recommend against primary prophylaxis with antiepileptics in patients with brain abscess. | Very low | Conditional |
Fleiss Kappa | 0.362 | 0.419 | 0.548 | 0.389 | 0.453 | 0.660 |