Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement

Evaluating the duration of antimicrobial therapy for the treatment of orthopedic hardware infections

The optimal duration of antimicrobial therapy for orthopedic hardware infections is unclear. We identified 216 patients with orthopedic hardware infections, of whom 42 (19%) later had relapsed infection. Chronic suppressive antimicrobial therapy beyond 12 weeks was not significantly associated with lower odds of relapse.IMPORTANCEThere is debate about how long to continue antibiotics after initial treatment of bone and joint infections when hardware remains in place. This study found no benefit from continuing antibiotics longer than 12 weeks when trying to prevent recurrent infection.

Evaluation and Management of Pelvic Osteomyelitis in Stage IV Pressure Injuries: A Multidisciplinary Collaborative Approach

Managing pelvic osteomyelitis (POM) in the setting of stage IV pressure injuries requires multidisciplinary evaluation as well as patient and caregiver engagement and is complicated by the lack of high-evidence data to guide best practices. In this review, we describe our approach to pressure injury and POM evaluation and management through multidisciplinary collaboration and highlight areas of future research that are necessary to enhance patient outcomes, reduce healthcare costs, and improve the quality of life of those affected by POM.

Surgical site infection surveillance in knee and hip arthroplasty: optimizing an algorithm to detect high-risk patients based on electronic health records

BACKGROUND

Surgical site infection (SSI) is an important cause of disease burden and healthcare costs. Fully manual surveillance is time-consuming and prone to subjectivity and inter-individual variability, which can be partly overcome by semi-automated surveillance. Algorithms used in orthopaedic SSI semi-automated surveillance have reported high sensitivity and important workload reduction. This study aimed to design and validate different algorithms to identify patients at high risk of SSI after hip or knee arthroplasty.

METHODS

Retrospective data from manual SSI surveillance between May 2015 and December 2017 were used as gold standard for validation. Knee and hip arthroplasty were included, patients were followed up for 90 days and European Centre for Disease Prevention and Control SSI classification was applied. Electronic health records data was used to generate different algorithms, considering combinations of the following variables: ≥1 positive culture, ≥ 3 microbiological requests, antimicrobial therapy ≥ 7 days, length of hospital stay ≥ 14 days, orthopaedics readmission, orthopaedics surgery and emergency department attendance. Sensitivity, specificity, negative and predictive value, and workload reduction were calculated.

RESULTS

In total 1631 surgical procedures were included, of which 67.5% (n = 1101) in women; patients' median age was 69 years (IQR 62 to 77) and median Charlson index 2 (IQR 1 to 3). Most surgeries were elective (92.5%; n = 1508) and half were hip arthroplasty (52.8%; n = 861). SSI incidence was 3.8% (n = 62), of which 64.5% were deep or organ/space infections. Positive culture was the single variable with highest sensitivity (64.5%), followed by orthopaedic reintervention (59.7%). Twenty-four algorithms presented 90.3% sensitivity for all SSI types and 100% for deep and organ/space SSI. Workload reduction ranged from 59.7 to 67.7%. The algorithm including ≥ 3 microbiological requests, length of hospital stay ≥ 14 days and emergency department attendance, was one of the best options in terms of sensitivity, workload reduction and feasibility for implementation.

CONCLUSIONS

Different algorithms with high sensitivity to detect all types of SSI can be used in real life, tailored to clinical practice and data availability. Emergency department attendance can be an important variable to identify superficial SSI in semi-automated surveillance.

Multisite Study of the Management of Musculoskeletal Infection After Trauma: The MMUSKIT Study

Background

The optimal duration and choice of antibiotic for fracture-related infection (FRI) is not well defined. This study aimed to determine whether antibiotic duration (≤6 vs >6 weeks) is associated with infection- and surgery-free survival. The secondary aim was to ascertain risk factors associated with surgery- and infection-free survival.

Methods

We performed a multicenter retrospective study of patients diagnosed with FRI between 2013 and 2022. The association between antibiotic duration and surgery- and infection-free survival was assessed by Cox proportional hazard models. Models were weighted by the inverse of the propensity score, calculated with a priori variables of hardware removal; infection due to Staphylococcus aureus, Staphylococcus lugdunensis, Pseudomonas or Candida species; and flap coverage. Multivariable Cox proportional hazard models were run with additional covariates including initial pathogen, need for flap, and hardware removal.

Results

Of 96 patients, 54 (56.3%) received ≤6 weeks of antibiotics and 42 (43.7%) received >6 weeks. There was no association between longer antibiotic duration and surgery-free survival (hazard ratio [HR], 0.95; 95% CI, .65-1.38; P = .78) or infection-free survival (HR, 0.77; 95% CI, .30-1.96; P = .58). Negative culture was associated with increased hazard of reoperation or death (HR, 3.52; 95% CI, 1.99-6.20; P < .001) and reinfection or death (HR, 3.71; 95% CI, 1.24-11.09; P < .001). Need for flap coverage had an increased hazard of reoperation or death (HR, 3.24; 95% CI, 1.61-6.54; P = .001).

Conclusions

The ideal duration of antibiotics to treat FRI is unclear. In this multicenter study, there was no association between antibiotic treatment duration and surgery- or infection-free survival.

High Efficacy of Oral Tetracyclines in Prosthetic Joint Infection Treated With Debridement, Antibiotics, and Implant Retention (DAIR) or Resection Arthroplasty With Destination Spacer Placement

Prosthetic joint infections are often managed with debridement and implant retention (DAIR) or resection arthroplasty with destination spacer placement. Both surgical approaches require long courses of postoperative antibiotics, for which tetracycline antibiotics have not been well-studied. In this retrospective case series, we included patients at our institution treated for staphylococcal prosthetic joint infection managed with DAIR or destination spacer placement who were switched from IV antibiotics to oral tetracycline within 12 weeks of surgery. Our primary outcome of interest was treatment failure within one year of initial surgery. Among the patients in our series, 88.2% (n = 15) of patients who underwent DAIR and 100% (n = 7) of patients who underwent resection arthroplasty with destination spacer remained event-free for one year. These results demonstrated that the use of oral tetracyclines as long-term therapy in the treatment of these infections was effective and well-tolerated.

Osteomyelitis and non-coding RNAS: A new dimension in disease understanding

Osteomyelitis, a debilitating bone infection, presents considerable clinical challenges due to its intricate etiology and limited treatment options. Despite strides in surgical and chemotherapeutic interventions, the treatment landscape for osteomyelitis remains unsatisfactory. Recent attention has focused on the role of non-coding RNAs (ncRNAs) in the pathogenesis and progression of osteomyelitis. This review consolidates current knowledge on the involvement of distinct classes of ncRNAs, including microRNAs, long ncRNAs, and circular RNAs, in the context of osteomyelitis. Emerging evidence from various studies underscores the potential of ncRNAs in orchestrating gene expression and influencing the differentiation of osteoblasts and osteoclasts, pivotal processes in bone formation. The review initiates by elucidating the regulatory functions of ncRNAs in fundamental cellular processes such as inflammation, immune response, and bone remodeling, pivotal in osteomyelitis pathology. It delves into the intricate network of interactions between ncRNAs and their target genes, illuminating how dysregulation contributes to the establishment and persistence of osteomyelitic infections. Understanding their regulatory roles may pave the way for targeted diagnostic tools and innovative therapeutic interventions, promising a paradigm shift in the clinical approach to this challenging condition. Additionally, we delve into the promising therapeutic applications of these molecules, envisioning novel diagnostic and treatment approaches to enhance the management of this challenging bone infection.

Rifampin Based Therapy for Patients With Staphylococcus aureus Native Vertebral Osteomyelitis: A Systematic Review and Meta-analysis

BACKGROUND

Native vertebral osteomyelitis (NVO) caused by Staphylococcus aureus is associated with high risk of treatment failure and increased morbidity. The role of rifampin-based therapy for the treatment of this condition is controversial. The goal of this systematic review and meta-analysis is to explore the efficacy and safety of rifampin-based therapy for the treatment of S. aureus NVO.

METHODS

We searched Cochrane, Embase, Medline, Scopus, and Web of Science databases for studies published up to May 2023, focusing on adults with NVO treated with or without rifampin-containing regimens. A random-effects model meta-analysis estimated relative risks and risk difference with 95% confidence intervals (CI).

RESULTS

Thirteen studies (2 randomized controlled trials and 11 comparative cohort studies), comprising 244 patients with S. aureus NVO who received rifampin and 435 who did not, were analyzed. Meta-analysis showed that rifampin-based regimens were associated with lower risk of clinical failure (risk difference, -14%; 95% CI, -19% to -8%; P < .001; I2 = 0%; relative risk, 0.58; 95% CI, .37-.92, P = .02, I2 = 21%). Only 1 study reported on adverse events. All studies had a high or uncertain risk of bias, and the certainty of evidence was rated as very low.

CONCLUSIONS

Adjunctive rifampin therapy might be associated with lower risk of S. aureus NVO treatment failure; however, the low certainty of evidence precludes drawing definitive conclusions that would alter clinical practice. A randomized trial is necessary to corroborate these findings.

Using antibiotics wisely

PURPOSE OF REVIEW

This review will describe role of shorter antibiotic therapies, early switch from intravenous to oral therapy, and artificial intelligence in infectious diseases.

RECENT FINDINGS

There is evidence that shorter courses of antibiotics are noninferior to standard durations of therapy. This has been demonstrated with Enterobacterales bacteremia that can be treated with 7 days of therapy, community acquired pneumonia with 3 days and ventilator associated pneumonia with just 7 days of antibiotic therapy. The conversion from intravenous to oral therapy in treating bacteremia, endocarditis and bone and joint infections is safe and effective and reduces line complications and costs. Also, for clean surgical procedures only one dose of antibiotic is needed, but it should be the most effective antibiotic which is cefazolin. This means avoiding clindamycin, removing penicillin allergies where possible for improved outcomes. Finally, the role of artificial intelligence to incorporate into using antibiotics wisely is rapidly emerging but is still in early stages.

SUMMARY

In using antibiotics wisely, targeting such as durations of therapy and conversion from intravenous antibiotic therapy to oral are low hanging fruit. The future of artificial intelligence could automate a lot of this work and is exciting but needs to be proven.

VIDEO ABSTRACT

http://links.lww.com/COID/A50.

Choosing patients over placebos: oral transitional therapy vs. IV-only therapy for bacteraemia and infective endocarditis

BACKGROUND

The belief that antibiotics must be administered intravenously (IV) to treat bacteraemia and endocarditis has its origins 70 years ago and has engrained itself in the psyche of the medical community and the public at large. This has led to hesitancy in adopting evidence-based strategies utilizing oral transitional therapy for the treatment of these infections. We aim to reframe the narrative around this debate, focusing on patient safety over vestigial psychology.

OBJECTIVES

This narrative review summarizes the current state of the literature regarding the use of oral transitional therapy for the treatment of bacteraemia and infective endocarditis, focusing on studies comparing it to the traditional, IV-only approach.

SOURCES

Relevant studies and abstracts from PubMed reviewed in April 2023.

CONTENT

Treating bacteraemia with oral transitional therapy has been studied in 9 randomized controlled trials (RCTs), totalling 625 patients, as well as numerous large, retrospective cohorts, including 3 published in the last 5 years alone, totalling 4763 patients. We identified 3 large, retrospective cohort studies; one quasi-experimental, pre-post study, and 3 RCTs of patients with endocarditis, totalling 748 patients in the retrospective cohorts and 815 patients in prospective, controlled studies. In all these studies, no worse outcomes were observed in the oral transitional therapy arm as compared with IV-only therapy. The main difference has consistently been longer durations of inpatient hospitalization and increased risk of catheter-related adverse events like venous thrombosis and line-associated blood stream infections in the IV-only groups.

IMPLICATIONS

There are ample data showing that choosing oral therapy reduces hospital stay and has fewer adverse events for patients than IV-only therapy, all with similar or better outcomes. In selected patients, choosing IV-only therapy may serve more as an anxiolytic "placebo" for the patient and provider rather than a necessity for treating the actual infection.

Clinical pharmacological considerations in an early intravenous to oral antibiotic switch: are barriers real or simply perceived?

BACKGROUND

Traditionally, there has been a common belief that ongoing i.v. antibiotic therapy is superior to an early i.v. to oral switch, especially for severe infections. However, this may be at least partly based on early observations rather than robust, high-quality data and contemporary clinical studies. It is important to examine whether these traditional views align with clinical pharmacological considerations, or conversely, if these considerations may support the broader application of an early i.v. to oral switch under appropriate circumstances.

OBJECTIVES

To examine the rationale for an early i.v. to oral antibiotic switch in the context of clinical pharmacokinetic and pharmacodynamic principles and to discuss whether commonly encountered pharmacological barriers are real or simply perceived.

SOURCES

We conducted PubMed searches on barriers and clinicians' perceptions about an early i.v. to oral switch, clinical studies comparing switching with i.v.-only dosing, and pharmacological factors affecting oral antimicrobials.

CONTENT

We focused on general pharmacological and clinical pharmacokinetic and pharmacodynamic principles and considerations that are relevant when clinicians ponder whether to switch from i.v. to oral antimicrobial dosing. The main focus of this review was on antibiotics. The discussion of the general principles is accompanied by specific examples from the literature.

IMPLICATIONS

Clinical pharmacological considerations and an imposing and increasing number of clinical studies, including randomized clinical trials, support an early i.v. to oral switch for the treatment of a number of infection types, under appropriate circumstances. We hope that the information provided here will add to calls for a critical examination of the role of i.v. to oral switching for many infections that are currently treated almost exclusively with i.v.-only therapy, and that it will inform health policy and guideline development by infectious diseases organizations.

Acute multifocal osteomyelitis with septic arthritis caused by nontyphoidal Salmonella in an immunocompetent young adult: a case report

Nontyphoidal Salmonella (NTS) infection can lead to gastroenteritis, enteric fever, and bacteremia. However, bone and joint infections due to NTS are rarely encountered, accounting for only 0.8% of all Salmonella infections and 0.45% of all types of osteomyelitis. We herein report an extremely rare case of acute multifocal osteomyelitis (bilateral femurs and left tibia) with septic arthritis of the bilateral hips caused by Salmonella Dublin in an immunocompetent adult. We performed thorough debridement of the bilateral hips and surgical decompression of the involved bones. At 1 year of follow-up, the patient's inflammatory biomarkers were within normal limits, and clinical and radiologic examinations showed no signs of infection. We emphasize that invasive NTS can lead to multifocal bone and joint infections in immunocompetent adults. The manifestations of Salmonella osteomyelitis may be insidious; thus, we recommend performing a simultaneous magnetic resonance imaging examination of the bone adjacent to the infected joint to avoid missed or delayed diagnosis. Thorough surgical debridement combined with a long course of sensitive antibiotic therapy is essential to eradicate the infection.

Early switch from intravenous to oral antibiotic treatment in bone and joint infections

OBJECTIVES

The timing of the switch from intravenous (i.v.) to oral antibiotic therapy for orthopaedic bone and joint infections (BJIs) is debated. In this narrative article, we discuss the evidence for and against an early switch in BJIs.

DATA SOURCES

We performed a PubMed and internet search investigating the association between the duration of i.v. treatment for BJI and remission of infection among adult orthopaedic patients.

CONTENT

Among eight randomized controlled trials and multiple retrospective studies, we failed to find any minimal duration of postsurgical i.v. therapy associated with clinical outcomes. We did not find scientific data to support the prolonged use of i.v. therapy or to inform a minimal duration of i.v.

THERAPY

Growing evidence supports the safety of an early switch to oral medications once the patient is clinically stable.

IMPLICATIONS

After surgery for BJI, a switch to oral antibiotics within a few days is reasonable in most cases. We recommend making the decision on the time point based on clinical criteria and in an interdisciplinary team at the bedside.

Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus Statement

Importance

Practice guidelines often provide recommendations in which the strength of the recommendation is dissociated from the quality of the evidence.

Objective

To create a clinical guideline for the diagnosis and management of adult bacterial infective endocarditis (IE) that addresses the gap between the evidence and recommendation strength.

Evidence Review

This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In April 2022 a call to new and existing members was released electronically (social media and email) for the next WikiGuidelines topic, and subsequently, topics and questions related to the diagnosis and management of adult bacterial IE were crowdsourced and prioritized by vote. For each topic, PubMed literature searches were conducted including all years and languages. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were crafted discussing the risks and benefits of different approaches.

Findings

A total of 51 members from 10 countries reviewed 587 articles and submitted information relevant to 4 sections: establishing the diagnosis of IE (9 questions); multidisciplinary IE teams (1 question); prophylaxis (2 questions); and treatment (5 questions). Of 17 unique questions, a clear recommendation could only be provided for 1 question: 3 randomized clinical trials have established that oral transitional therapy is at least as effective as intravenous (IV)-only therapy for the treatment of IE. Clinical reviews were generated for the remaining questions.

Conclusions and Relevance

In this consensus statement that applied the WikiGuideline method for clinical guideline development, oral transitional therapy was at least as effective as IV-only therapy for the treatment of IE. Several randomized clinical trials are underway to inform other areas of practice, and further research is needed.

Management of Complex Infections in Hemophagocytic Lymphohistiocytosis in Adults

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune system activation and inflammatory response due to a variety of primary and secondary factors that can cause a range of clinical symptoms and, in severe cases, life-threatening conditions. Patients with HLH are at increased risk of infection due to their abnormal immune function as well as chemotherapy and immunosuppressive therapy at the time of treatment. At the same time, the lack of specific clinical features makes complex infections in HLH challenging to diagnose and treat. The management of complex infections in HLH requires a multidisciplinary and integrated approach including the early identification of pathogens, the development of anti-infection protocols and regimens, and the elimination of potential infection factors. Especially in HLH patients with septic shock, empirical combination therapy against the most likely pathogens should be initiated, and appropriate anti-infective regimens should be determined based on immune status, site of infection, pathogens, and their drug resistance, with timely antibiotic adjustment by monitoring procalcitonin. In addition, anti-infection prophylaxis for HLH patients is needed to reduce the risk of infection such as prophylactic antibiotics and vaccinations. In conclusion, complex infection in HLH is a serious and challenging disease that requires vigilance, early identification, and timely anti-infective therapy.

Oral-only antibiotics for bone and joint infections in children: study protocol for a nationwide randomised open-label non-inferiority trial

INTRODUCTION

Children with bone and joint infections are traditionally treated with intravenous antibiotics for 3-10 days, followed by oral antibiotics. Oral-only treatment has not been tested in randomised trials.

METHODS AND ANALYSIS

Children (3 months to 18 years) will be randomised 1:1 with the experimental group receiving high-dose oral antibiotics and the control group receiving intravenous antibiotics with a shift in both groups to standard oral antibiotics after clinical and paraclinical improvement. Children in need of acute surgery or systemic features requiring intravenous therapy, including septic shock, are excluded. The primary outcome is defined as a normal blinded standardised clinical assessment 6 months after end of treatment. Secondary outcomes are non-acute treatment failure and recurrent infection. Outcomes will be compared by a non-inferiority assumption with an inferiority margin of 5%.

ETHICS AND DISSEMINATION

The trial has the potential to reduce unnecessary hospitalisation and use of intravenous antibiotics in children with bone or joint infections. Due to the close follow-up, exclusion of severely ill children and predefined criteria for discontinuation of the allocated therapy, we expect the risk of treatment failure to be minimal.

TRIAL REGISTRATION NUMBER

NCT04563325.

When Oral Therapy Can Replace Intravenous Antibiotics-Changing Practice as New Data Emerge

This essay describes a physician-patient’s experience with unchanged practice patterns despite the publication of new data challenging those patterns.

Short Antibiotic Treatment Duration for Osteomyelitis Complicating Pressure Ulcers: A Quasi-experimental Study

Background

Osteomyelitis-complicating pressure ulcers are frequent among patients with spinal cord injuries (SCIs), and the optimal management is unknown. In our referral center, the current management is debridement and flap coverage surgeries, followed by a short antibiotic treatment. We aimed to evaluate patients' outcomes a year after surgery.

Methods

We performed a quasi-experimental retrospective before/after study on SCI patients with presumed osteomyelitis associated with perineal pressure ulcers. We included all patients who underwent surgery with debridement and flap covering, followed by effective antibiotic treatment, between May 1, 2016, and October 30, 2020. The effective antimicrobial treatment duration included the 10 days leading up to January 1, 2018 (before period), and the 5 to 7 days after (after period). We also compared the efficacy of 5-7-day vs 10-day antibiotic treatment and performed uni- and multivariable analyses to identify factors associated with failure.

Results

Overall, 415 patients were included (77.6% male patients; mean age ± SD, 53.0 ± 14.4 years). Multidrug-resistant organisms (MDROs) were involved in 20.7% of cases. Favorable outcomes were recorded in 69.2% of cases: 117/179 (65.3%) in the 10-day treatment group vs 169/287 (71.9%) in the 5-7-day treatment group (P = .153). The only factor associated with failure in the multivariate analysis was a positive culture from suction drainage (odds ratio, 1.622; 95% CI, 1.005-2.617; P = .046). Effective treatment duration >7 days and intraoperative samples negative for MDROs were not associated with better outcomes (P = .153 and P = .241, respectively).

Conclusions

A treatment strategy combining surgical debridement and flap covering, followed by 5 to 7 days of effective antibiotic treatment seems safe.

Short-course antibiotics for common infections: what do we know and where do we go from here?

BACKGROUND

Over the past 25 years, researchers have performed >120 randomized controlled trials (RCTs) illustrating short courses to be non-inferior to long courses of antibiotics for common bacterial infections.

OBJECTIVE

We sought to determine whether clinical data from RCTs affirm the mantra of 'shorter is better' for antibiotic durations in 7 common infections: pneumonia, urinary tract infection, intra-abdominal infection, bacteraemia, skin and soft tissue infection, bone and joint infections, pharyngitis and sinusitis.

SOURCES

Published RCTs comparing short- versus long-course antibiotic durations were identified through searches of PubMed and clinical guideline documents.

CONTENT

Short-course antibiotic durations consistently result in similar treatment success rates as longer antibiotic courses among patients with community-acquired pneumonia, complicated urinary tract infections in women, gram-negative bacteraemia, and skin and soft tissue infections when the diagnosis is confirmed, appropriate antimicrobials are used, and patients show clinical signs of improvement. For patients with osteomyelitis, 6 weeks of antibiotics is adequate for the treatment of osteomyelitis in the absence of implanted foreign bodies and surgical debridement. Whether durations can be further shortened with debridement is unclear, although small studies are promising.

IMPLICATIONS

With few exceptions, short courses were non-inferior to long courses; future research should focus on appropriately defining the patient population, ensuring the correct choice and dose of antimicrobials and developing meaningful outcomes relevant for frontline clinicians.

Septic arthritis with osteomyelitis due to Salmonella enterica serotype Dublin: A case series

Background

Septic arthritis with osteomyelitis due to Salmonella enterica serotype Dublin is rare. We reviewed and analyzed cases of septic arthritis with osteomyelitis due to Salmonella enterica serotype Dublin seen at our institution.

Methods

The medical records of all patients diagnosed with Salmonella septic arthritis and/or Salmonella osteomyelitis during 2017-2022 were included. We reviewed the diagnosis, medical history, clinical management, and outcome of all cases.

Results

Five patients with Salmonella septic arthritis or Salmonella osteomyelitis were identified during the 5-year study period. They were all male; the median age was 53 years (range 15-56). Only one was immunodeficient. All five patients were infected at the hip joint and ipsilateral femur, while two suffered bilateral hip septic arthritis with femoral osteomyelitis. Salmonella Dublin was isolated from the hip joint fluid of all patients. Four presented with fever and constitutional signs within four weeks of symptom onset. Four had positive blood cultures, and only one patient had gastrointestinal symptoms. Four patients underwent surgical debridement as the primary surgical plan, and two underwent secondary two-stage exchange after primary surgical debridement failure. The last patient had a two-stage exchange directly as the first surgical treatment. All patients received intravenous antimicrobial therapy for a median duration of 6 (range 4-12) weeks and oral antimicrobial therapy for a median duration of 4 (range 4-6) weeks. All patients had a median duration of follow-up of 12 months (range 9-25), and none had evidence of recurrence of infection.

Conclusions

Septic arthritis due to Salmonella Dublin remains rare. It frequently occurs with ipsilateral femur osteomyelitis adjacent to the infected hip joint in our cases. Surgical debridement or two-stage exchange, along with 4-12 weeks of effective intravenous and followed by 4-6 oral antimicrobial therapy, could successfully eradicate the infection.

Cutibacterium acnes in spine tissue: characteristics and outcomes of non-hardware-associated vertebral osteomyelitis

Cutibacterium acnes isolation from spine tissue can be challenging because the organism can represent a contaminant. There is a paucity of data regarding the role of C. acnes in non-hardware-associated vertebral osteomyelitis (VO). Herein we evaluate the clinical and microbiological characteristics, treatment, and outcome of patients with C. acnes VO. Data were retrospectively collected from adults with a positive spine culture for C. acnes at Mayo Clinic, Rochester (MN), from 2011 to 2021. Patients with spinal hardware and polymicrobial infections were excluded. Of the subjects, 16 showed radiological and clinical findings of VO: 87.5 % were male, the average age was 58 years (±15 SD), and back pain was the predominant symptom. Of the lesions, 89.5 % involved the thoracic spine. Of the subjects, 69 % had experienced an antecedent event at the site of VO. In five subjects, C. acnes was isolated after 7 d of anaerobic culture incubation. Thirteen subjects were treated with parenteral β-lactams, and three with oral antimicrobials, without any evidence of recurrence. Twenty-one subjects were not treated for VO, as C. acnes was considered a contaminant; at follow-up, none had evidence of progressive disease. C. acnes should be part of microbiological differential diagnosis in patients with suspected VO, especially in the context of a prior spinal procedure. Anaerobic spine cultures should undergo prolonged incubation to enable recovery of C. acnes. C. acnes VO may be managed with oral or parenteral antimicrobial therapy. Without clinical and radiological evidence of VO, a single positive culture of C. acnes from spine tissue frequently represents contaminants.

Can the Future of ID Escape the Inertial Dogma of Its Past? The Exemplars of Shorter Is Better and Oral Is the New IV

Like all fields of medicine, Infectious Diseases is rife with dogma that underpins much clinical practice. In this study, we discuss 2 specific examples of historical practice that have been overturned recently by numerous prospective studies: traditional durations of antimicrobial therapy and the necessity of intravenous (IV)-only therapy for specific infectious syndromes. These dogmas are based on uncontrolled case series from >50 years ago, amplified by the opinions of eminent experts. In contrast, more than 120 modern, randomized controlled trials have established that shorter durations of therapy are equally effective for many infections. Furthermore, 21 concordant randomized controlled trials have demonstrated that oral antibiotic therapy is at least as effective as IV-only therapy for osteomyelitis, bacteremia, and endocarditis. Nevertheless, practitioners in many clinical settings remain refractory to adopting these changes. It is time for Infectious Diseases to move beyond its history of eminent opinion-based medicine and truly into the era of evidenced-based medicine.

Early switch to oral antibiotic therapy for the treatment of patients with bacterial native vertebral osteomyelitis: a quaternary center experience, systematic review, and meta-analysis

Abstract. Recent data suggest that oral therapy can be effective for bone infections. We aim to assess the efficacy of an early switch to oral therapy (<2 weeks) compared to a non-early switch in bacterial native vertebral osteomyelitis. We conducted a cohort study at Mayo Clinic, Rochester (MN), between 2019–2021 combined with a systematic review, which queried multiple databases. Data were analyzed using a random-effects model. The cohort study included 139 patients: two received an early switch. Of 3708 citations, 13 studies were included in the final analysis. Meta-analysis demonstrated no difference in treatment failure (odds ratio = 1.073, 95 % confidence interval 0.370–3.116), but many studies presented high risk of bias. Current evidence is insufficient to conclude the proportion of patients with failure or relapse is different in the two groups. High-quality studies are warranted before early switch can be routinely recommended.

What Is the Best Oral Therapy for Staph aureus Osteomyelitis?

Best Oral Therapy for Staph aureus OsteomyelitisA 50-year-old patient with diabetes mellitus has a plantar ulcer at the base of the first metatarsal. Cortical erosions are noted; bone biopsy culture yields Staphylococcus aureus susceptible to methicillin, ciprofloxacin, clindamycin, doxycycline, trimethoprim/sulfamethoxazole, linezolid, and rifampin. The plan is for 4 weeks of antibiotic treatment. Which antibiotic should be prescribed?

Eligibility for and Use of Oral Antimicrobial Therapy Among Veterans With Osteoarticular Infections: A Retrospective Study Across 8 Medical Centers

We retrospectively evaluated antimicrobial therapy in 145 randomly selected patients with osteoarticular infections across 8 hospitals. One hundred nine (75%) were eligible for oral antimicrobial therapy, but only 18 received it: 5 of 39 (13%) in 2018 versus 13 of 70 (19%) in 2019-2020 (P = .44). Oral antimicrobials may be underutilized for osteoarticular infections in routine practice.