Cardiogenic brain abscesses in children: the recurrence paradox in a 24-year institutional experience with 571.9 person-years of follow-up

Cardiogenic brain abscesses (CBA) are rare infections that primarily affect children with cyanotic congenital heart disease (CCHD). Despite longstanding clinical awareness, gaps remain in our understanding of long-term outcomes and the actual recurrence risk. This study analyzed the clinical profile, management, and long-term outcomes of a large institutional cohort, with an emphasis on quantifying the recurrence risk.

We retrospectively reviewed the records of 34 pediatric patients (aged < 15 years at index abscess diagnosis) who underwent CBA management at our institution between January 2001 and February 2025. Data on clinical presentation, microbiology, surgical intervention, and cardiac status were also collected. Long-term follow-up was conducted using clinical records and standardized telephone surveys.

The mean age at presentation was 8.2 years. Streptococcus spp. was the most common isolate (15/34), and 44% of the cultures were negative. Management primarily involved burr-hole aspiration (33/34). The cohort accumulated 571.9 person-years of follow-up, which is the largest cumulative exposure reported in the CBA literature. The mean follow-up was 16.82 years (range, 4–24). Despite 19 patients (55.9%) maintaining a persistent hypoxic milieu, no recurrences were observed (0/34; 95% CI: 0–10.3%). Seven patients (20.5%) died of cardiac causes, and no deaths were attributable to the abscess after the perioperative period. All the survivors demonstrated favorable neurological outcomes.

CBA recurrence is rare following appropriate treatment, which challenges conventional pathogenic models. The long-term prognosis is determined by cardiac status rather than neurological factors. With 571.9 person-years of observation, we provided robust evidence that recurrence is genuinely rare, and we propose a structured management algorithm derived from our institutional experience.