Spontaneous pyogenic vertebral osteomyelitis and endocarditis: incidence, risk factors, and outcome

Wide variability of the definitions used for native vertebral osteomyelitis: walking the path for a unified diagnostic framework with a meta-epidemiological approach

BACKGROUND CONTEXT

Native Vertebral Osteomyelitis (NVO) has seen a rise in incidence, yet clinical outcomes remain poor with high relapse rates and significant long-term sequelae. The 2015 IDSA Clinical Practice Guidelines initiated a surge in scholarly activity on NVO, revealing a patchwork of definitions and numerous synonyms used interchangeably for this syndrome.

PURPOSE

To systematically summarize these definitions, evaluate their content, distribution over time, and thematic clustering.

STUDY DESIGN/SETTING

Meta-epidemiological study with a systematic review of definitions.

PATIENTS SAMPLE

An extensive search of multiple databases was conducted, targeting trials and cohort studies dating from 2005 to present, providing a definition for NVO and its synonyms.

OUTCOME MEASURES

Analysis of the diagnostic criteria that composed the definitions and the breaking up of the definitions in the possible combinations of diagnostic criteria.

METHODS

We pursued a thematic synthesis of the published definitions with Boolean logic, yielding single or multiple definitions per included study. Using 8 predefined diagnostic criteria, we standardized definitions, focusing on the minimum necessary combinations used. Definition components were visualized using Sankey diagrams.

RESULTS

The literature search identified 8,460 references, leading to 171 studies reporting on 21,963 patients. Of these, 91.2% were retrospective, 7.6% prospective, and 1.2% RCTs. Most definitions originated from authors, with 29.2% referencing sources. We identified 92 unique combinations of diagnostic criteria across the literature. Thirteen main patterns emerged, with the most common being clinical features with imaging, followed by clinical features combined with imaging and microbiology, and lastly, imaging paired with microbiology.

CONCLUSIONS

Our findings underscore the need for a collaborative effort to develop standardized diagnostic criteria. We advocate for a future Delphi consensus among experts to establish a unified diagnostic framework for NVO, emphasizing the core components of clinical features and MRI while incorporating microbiological and histopathological insights to improve both patient outcomes and research advancements.

The projected increase of vertebral osteomyelitis in Germany implies a demanding challenge for future healthcare management of aging populations

PURPOSE

Since an increase in the occurrence of native vertebral osteomyelitis (VO) is expected and reliable projections are missing, it is urgent to provide a reliable forecast model and make it a part of future health care considerations.

METHODS

Comprehensive nationwide data provided by the Federal Statistical Office of Germany were used to forecast total numbers and incidence rates (IR) of VO as a function of age and gender until 2040. Projections were done using autoregressive integrated moving average model on historical data from 2005 to 2019 in relation to official population projections from 2020 to 2040.

RESULTS

The IR of VO is expected to increase from 12.4 in 2019 to 21.5 per 100,000 inhabitants [95% CI 20.9-22.1] in 2040. The highest increase is predicted in patients over 75 years of age for both men and women leading to a steep increase in absolute numbers, which is fourfold higher compared to patients younger than 75 years. While the IR per age group will not increase any further after 2035, the subsequent increase is due to a higher number of individuals aged 75 years or older.

CONCLUSIONS

Our data suggest that increasing IR of VO will seriously challenge healthcare systems, particularly due to demographic change and increasing proportions of populations turning 75 years and older. With respect to globally fast aging populations, future health care policies need to address this burden by anticipating limitations in financial and human resources and developing high-level evidence-based guidelines for prevention and interdisciplinary treatment.

Infective endocarditis and spondylodiscitis-impact of sequence of surgical therapy on survival and recurrence rate

OBJECTIVES

To date, there are no standardized treatment algorithms or recommendations for patients with infective endocarditis (IE) and concomitant spondylodiscitis (SD). Therefore, our aim was to analyse whether the sequence of surgical treatment of IE and SD has an impact on postoperative outcome and to identify risk factors for survival and postoperative recurrence.

METHODS

Patients with IE underwent surgery in 4 German university hospitals between 1994 and 2022. Univariable and multivariable analyses were performed to identify possible predictors of 30-day/1-year mortality and recurrence of IE and/or SD.

RESULTS

From the total IE cohort (n = 3991), 150 patients (4.4%) had concomitant SD. Primary surgery for IE was performed in 76.6%, and primary surgery for SD in 23.3%. The median age was 70.0 (64.0-75.6) years and patients were mostly male (79.5%). The most common pathogens detected were enterococci and Staphylococcus aureus followed by streptococci, and coagulase-negative Staphylococci. If SD was operated on first, 30-day mortality was significantly higher than if IE was operated on 1st (25.7% vs 11.4%; P = 0.037) and we observed a tendency for a higher 1-year mortality. If IE was treated 1st, we observed a higher recurrence rate within 1 year (12.2% vs 0%; P = 0.023). Multivariable analysis showed that primary surgery for SD was an independent predictor of 30-day mortality.

CONCLUSIONS

Primary surgical treatment for SD was an independent risk factor for 30-day mortality. When IE was treated surgically 1st, the recurrence rate of IE and/or SD was higher.

Imaging of Spondylodiscitis: A Comprehensive Updated Review-Multimodality Imaging Findings, Differential Diagnosis, and Specific Microorganisms Detection

Spondylodiscitis is defined by infectious conditions involving the vertebral column. The incidence of the disease has constantly increased over the last decades. Imaging plays a key role in each phase of the disease. Indeed, radiological tools are fundamental in (i) the initial diagnostic recognition of spondylodiscitis, (ii) the differentiation against inflammatory, degenerative, or calcific etiologies, (iii) the disease staging, as well as (iv) to provide clues to orient towards the microorganisms involved. This latter aim can be achieved with a mini-invasive procedure (e.g., CT-guided biopsy) or can be non-invasively supposed by the analysis of the CT, positron emission tomography (PET) CT, or MRI features displayed. Hence, this comprehensive review aims to summarize all the multimodality imaging features of spondylodiscitis. This, with the goal of serving as a reference for Physicians (infectious disease specialists, spine surgeons, radiologists) involved in the care of these patients. Nonetheless, this review article may offer starting points for future research articles.

Right ventricular papillary muscle crossing the moderator band mimicked infective endocarditis: the utility of multimodal imaging

Right-sided infective endocarditis (RSIE) generally carries a positive prognosis; however, it can result in complications such as heart failure, underscoring the importance of prompt diagnosis. While echocardiography serves as the standard diagnostic tool, it may occasionally face challenges in distinguishing between normal structures and vegetations. In this report, we present the case of a 60-year-old man diagnosed with pyogenic vertebral osteomyelitis, alongside suspected coexisting RSIE. During both transthoracic and transesophageal echocardiography, a rod-like mobile structure was observed adjacent to the right ventricular moderator band. However, confirming its nature as an infective vegetation proved challenging. Despite the inconclusive diagnosis of IE by echocardiography, the positron emission tomography/computed tomography (PET/CT) scan and cardiac magnetic resonance imaging (MRI) played a pivotal role in distinguishing between normal structures and vegetations. Since IE could develop life-threatening events, the role of multimodal imaging is of paramount importance. This case serves as a compelling example of the diagnostic value through the integration of PET/CT and MRI in ruling out IE.

Pyogenic spondylodiscitis in HIV-positive patients under antiretroviral therapy: A case series

Background: The incidence of pyogenic spondylodiscitis has been increasing in countries of Europe and North America, probably due to an increasing number of persons with risk factors for this infection. It is unclear whether HIV infection in the era of antiretroviral therapy (ART) increases the risk for spondylodiscitis. Method: We present 7 cases of pyogenic spondylodiscitis of the cervical, thoracic, and lumbar spine in six individuals living with HIV under ART with suppressed viral load. Results: All patients presented with severe non-radicular pain and elevated inflammatory markers. Diagnosis was confirmed by magnetic resonance imaging (MRI) scan and isolation of the pathogen. Staphylococcus aureus was the causative pathogen in five patients. One patient suffered from an infection with Klebsiella pneumoniae followed by a mixed infection with Cutibacterium acnes and Bacillus circulans 18 months later. All patients needed surgical intervention, and the mean duration of antibiotic treatment was 17 weeks (range 12-26). Five patients recovered fully, including two persons who also suffered from endocarditis. One patient died from multi-organ failure. Conclusion: Spondylodiscitis may be seen more frequently in persons living with HIV as they grow older and suffer from comorbidities which put them at risk for this infection. HIV physicians should be aware of the infection and its risk factors.

The impact of concomitant infective endocarditis in patients with spondylodiscitis and isolated spinal epidural empyema and the diagnostic accuracy of the modified duke criteria

Background

The co-occurrence of infective endocarditis (IE) and primary spinal infections (PSI) like spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been reported in up to 30% of cases and represents a life-threatening infection that requires multidisciplinary management to be successful. Therefore, we aimed to characterize the clinical phenotypes of PSI patients with concomitant IE and furthermore to assess the accuracy of the modified Duke criteria in this specific population.

Methods

We conducted a retrospective cohort study in consecutive SD and ISEE patients treated surgically at our University Spine Center between 2002 and 2022 who have undergone detailed phenotyping comprising demographic, clinical, imaging, laboratory, and microbiologic assessment. Comparisons were performed between PSI patients with IE (PSICIE) and without IE (PSIWIE) to identify essential differences.

Results

Methicillin-susceptible Staphylococcus aureus (MSSA) was the most common causative pathogen in PSICIE group (13 patients, 54.2%) and aortic valve IE was the most common type of IE (12 patients, 50%), followed by mitral valve IE (5 patients, 20.8%). Hepatic cirrhosis (p < 0.011; OR: 4.383; 95% CI: 1.405-13.671), septic embolism (p < 0.005; OR: 4.387; 95% CI: 1.555-12.380), and infection with Streptococcus spp. and Enterococcus spp. (p < 0.003; OR: 13.830; 95% CI: 2.454-77.929) were identified as significant independent risk factors for the co-occurrence of IE and PSI in our cohort. The modified Duke criteria demonstrated a sensitivity of 100% and a specificity of 66.7% for the detection of IE in PSI patients. Pathogens were detected more frequently via blood cultures in the PSICIE group than in the PSIWIE group (PSICIE: 23, 95.8% vs. PSIWIE: 88, 62.4%, p < 0.001). Hepatic cirrhosis (PSICIE: 10, 41.7% vs. PSIWIE: 33, 21.6%, p = 0.042), pleural abscess (PSICIE: 9, 37.5% vs. PSIWIE: 25, 16.3%, p = 0.024), sepsis (PSICIE: 20, 83.3% vs. PSIWIE: 67, 43.8%, p < 0.001), septic embolism (PSICIE: 16/23, 69.6% vs. PSIWIE: 37/134, 27. 6%, p < 0.001) and meningism (PSICIE: 8/23, 34.8% vs. PSIWIE: 21/152, 13.8%, p = 0.030) occurred more frequently in PSICIE than in PSIWIE patients. PSICIE patients received longer intravenous antibiotic therapy (PSICIE: 6 [4-7] w vs. PSIWIE: 4 [2.5-6] w, p < 0.001) and prolonged total antibiotic therapy overall (PSICIE: 11 [7.75-12] w vs. PSIWIE: 8 [6-12] w, p = 0.014). PSICIE patients spent more time in the hospital than PSIWIE (PSICIE: 43.5 [33.5-53.5] days vs. PSIWIE: 31 [22-44] days, p = 0.003).

Conclusions

We report distinct clinical, radiological, and microbiological phenotypes in PSICIE and PSIWIE patients and further demonstrate the diagnostic accuracy of the modified Duke criteria in patients with PSI and concomitant IE. In the high-risk population of PSI patients, the modified Duke criteria might benefit from amending pleural abscess, meningism, and sepsis as minor criteria and hepatic cirrhosis as major criterion.

The importance of the bacterial spectrum in the clinical diagnostics and management of patients with spontaneous pyogenic spondylodiscitis and isolated spinal epidural empyema: a 20-year cohort study at a single spine center

BACKGROUND

Personalized clinical management of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) is challenging due to limited evidence of microbiologic findings and their clinical impact during the clinical course of the disease. We aimed to characterize clinico-microbiological and imaging phenotypes of SD and ISEE to provide useful insights that could improve outcomes and potentially modify guidelines.

METHODS

We performed chart review and collected data on the following parameters: bacterial antibiogram-resistogram, type of primary spinal infection, location of spinal infection, source of infection, method of detection, clinical complications (sepsis, septic embolism, and endocarditis), length of hospital and intensive care unit (ICU) stay, relapse rate, and disease-related mortality in patients with proven pyogenic SD and ISEE treated surgically in a university hospital in Germany between 2002 and 2022.

RESULTS

We included data from 187 patients (125 SD, 66.8% and 62 ISEE, 33.2%). Gram-positive bacteria (GPB) were overall more frequently detected than gram-negative bacteria (GNB) (GPB: 162, 86.6% vs. GNB: 25, 13.4%, p < 0.001). Infective endocarditis was caused only by GPB (GPB: 23, 16.5% vs. GNB: 0, 0.0%, p = 0.046). Methicillin-susceptible Staphylococcus aureus was the most frequently isolated strain (MSSA: n = 100, 53.5%), occurred more frequently in the cervical spine compared to other bacteria (OB) (MSSA: 41, 41.0% vs. OB: 18, 20.7%, p = 0.004) and was most frequently detected in patients with skin infection as the primary source of infection (MSSA: 26, 40.6% vs. OB: 11, 16.7%, p = 0.002). Streptococcus spp. and Enterococcus spp. (SE: n = 31, 16.6%) were more often regarded as the cause of endocarditis (SE: 8, 27.6% vs. OB: 15, 11.4%, p = 0.037) and were less frequently detected in intraoperative specimens (SE: 19, 61.3% vs. OB: 138, 88.5%, p < 0.001). Enterobacterales (E: n = 20, 10.7%) were identified more frequently in urinary tract infections (E: 9, 50.0% vs. OB: 4, 3.6%, p < 0.001). Coagulase-negative Staphylococci (CoNS: n = 20, 10.7%) were characterized by a lower prevalence of sepsis (CoNS: 4, 20.0% vs. OB: 90, 53.9%, p = 0.004) and were more frequently detected in intraoperative specimens (CoNS: 20, 100. 0% vs. OB: 137, 82.0%, p = 0.048). Moreover, CoNS-associated cases showed a shorter length of ICU stay (CoNS: 2 [1-18] days vs. OB: 6 [1-53] days, median [interquartile range], p = 0.037), and occurred more frequently due to foreign body-associated infections (CoNS: 8, 61.5% vs. OB: 15, 12.8%, p = 0.008). The presence of methicillin-resistant Staphylococcus aureus (MRSA) prolonged hospital stay by 56 [24-58] days and ICU stay by 16 [1-44] days, whereas patients with Pseudomonas aeruginosa spent only 20 [18-29] days in the hospital and no day in the ICU 0 [0-5] days.

CONCLUSIONS

Our retrospective cohort study identified distinct bacterial-specific manifestations in pyogenic SD and ISEE regarding clinical course, neuroanatomic targets, method of pathogen detection, and sources of infection. The clinico-microbiological patterns varied depending on the specific pathogens.

The Impact of Patient Characteristics on Outcomes of Surgically Managed Vertebral Osteomyelitis in the United States: Insights from a National Database Study

This study was conducted to assess the patient characteristics, types of treatment, and outcomes of patients who are surgically treated for vertebral osteomyelitis (VO) in the United States. VO can be treated with or without surgical intervention. Surgically treated cases of VO are associated with significant morbidity and mortality, and incur major healthcare costs. There are few studies assessing the characteristics and outcomes of patients with VO who are treated surgically, as well as the overall impact of surgically managed VO on the healthcare system of the United States. Utilizing the Nationwide Inpatient Sample (NIS) database, 44,401 patients were identified who underwent surgical treatment for VO over a fifteen year period. Severity of comorbidity burden was calculated using the Deyo Index (DI). Surgical approach and comorbidities were analyzed in regard to their impact on complications, mortality rate, LOS, and hospitalization charges. The incidence of surgical intervention for patients who had VO increased from 0.6 to 1.1 per U.S. persons over the study period. Surgically treated patients had a mean age of 56 years, were 75.8% white, were 54.5% male, 37.9% carried Medicare insurance, and they had a mean DI of 0.88. Anterior/posterior approach (OR: 3.53), thoracolumbar fusion (OR: 2.69), thoracolumbar fusion (OR: 19.94), and anterior/posterior approach (OR: 64.73) were the surgical factors that most significantly predicted any complication, mortality, increased LOS, and increased hospital charges, respectively (P < 0.001). The mean inflation-adjusted total hospital cost increased from $20,355 to $39,991 per patient over the study period. VO has been steadily increasing in the United States. Incidence and inflation-adjusted costs nearly doubled. Anterior/posterior approach and thoracolumbar fusion most significantly predicted negative outcomes. VO is associated with lengthy and expensive hospital stays resulting in a significant burden to patients and the healthcare system.

Vertebral osteomyelitis secondary to infective endocarditis detected by repeated magnetic resonance imaging: a case report

Background

Patients with infective endocarditis (IE) experience various symptoms, a major one being back pain, which is occasionally caused by concomitant vertebral osteomyelitis (VO). Magnetic resonance imaging (MRI) is generally used to detect VO; however, the sensitivity of detection using MRI is very low in the early stages of VO.

Case summary

A 60-year-old man visited our hospital with complaints of fever and persistent back pain over the past 7 days. A holosystolic heart murmur was auscultated, and an echocardiography revealed a vegetation on the posterior mitral leaflet. Blood cultures were positive for Streptococcus sanguinis. He was diagnosed with IE and treated with antimicrobials. A lumbar spine MRI on Day 1 showed no clear signs of vertebral infection, but the back pain continued and gradually worsened. Magnetic resonance imaging retest on Day 8 showed high signal intensity within the lumbar vertebral bodies and the disk on T2-weighted sequences, indicating VO. Intravenous antimicrobial therapy was extended, followed by oral antimicrobials, and a corset was put on to protect the lumbar spine to prevent bone degradation.

Discussion

For persistent back pain in IE patients, repeat MRIs at regular intervals of time can detect possible vertebral infection even if signs of vertebral infection were absent on the initial MRI.

Discitis-osteomyelitis: optimizing results of percutaneous sampling

Vertebral discitis-osteomyelitis is an infection of the spine that involves the intervertebral disc and the adjacent vertebral body but may also extend into the paraspinal and epidural soft tissues. If blood cultures and other culture data fail to identify a causative microorganism, percutaneous sampling is indicated to help guide targeted antimicrobial therapy. Despite limited supporting evidence, withholding antimicrobial therapy for up to 2 weeks is recommended to maximize microbiological yield, although literature supporting this recommendation is limited. During the procedure, technical factors that may improve yield include targeting of paraspinal fluid collections or soft tissue abnormalities for sampling, acquiring multiple core samples if possible, and use of larger gauge needles when available. Repeat sampling may be indicated if initial percutaneous biopsy is negative but should be performed no sooner than 72 h after the initial percutaneous biopsy to ensure adequate time for culture results to return.

[Spondylodiscitis]

Spondylodiscitis is a severe infectious disease of the spine that affects the intervertebral discs and adjacent vertebrae. It can lead to nonspecific pain, limited mobility, and destruction of spinal structures. Various pathogens, such as bacteria, fungi, or parasites, can trigger the disease. An early diagnosis and targeted treatment are crucial to reduce the risk of serious complications. Magnetic resonance imaging (MRI) with contrast agent and blood tests are essential for the diagnosis and assessing the course of the disease. The treatment includes conservative and surgical approaches. Conservative treatment consists of a minimum 6‑week antibiotic course and immobilization of the affected area. Surgical interventions, along with several weeks of antibiotic therapy, are indicated for instabilities or complications in order to eliminate the infection focus and to restore spinal stability.

Clinical Characteristics of 96 Patients Presenting With Hematogenous Spinal Osteomyelitis- a Retrospective Study

OBJECTIVE

To report clinical characteristics and course of care for patients diagnosed with hematogenous spinal osteomyelitis (HVO).

METHODS

Medical records of patients presenting to two tertiary care centers with HVO were reviewed.

RESULTS

96 consecutive patients with HVO were identified. Mean follow-up was 8.9 months. Most infections occurred in the lumbar region (50.0%). Of the cultures taken, MRSA accounted for 9%; MSSA, 26%; Streptococcus species, 12%; other gram-positive bacteria, 23%; gram-negative, 17%; fungal, 2.6%; and 11.5% of cultures returned no growth. 57 patients underwent surgery. Of these, 79% of the patients had undergone a trial of empiric antibiotics (cefepime and vancomycin) of the day prior to surgery. 44% underwent secondary surgeries, typically due to a heavy wound burden of necrotic tissue and pus. Postoperative antibiotics were prescribed to all patients. 51.6% of the patients were prescribed antibiotic therapy >6 months. Overall mortality rate was 3.8%. Major cause of all deaths was septic shock. Post-infection sequelae occurred in 47.4% of patients. The most common sequelae were persistent or new sites of infection, sepsis, and abscess.

CONCLUSIONS

Diabetes, hypertension, and renal failure appear to increase the risk of post-infection sequelae and death. While non-operative management was attempted in nearly 47%, ultimately 73% had surgery. This high rate may reflect our population of patients hospitalized in a tertiary care center. Available data suggests that patients presenting with hematogenous osteomyelitis be followed closely as failure of non-operative management, and resulting morbidity, was high.

Diagnostic Sensitivity of Blood Culture, Intraoperative Specimen, and Computed Tomography-Guided Biopsy in Patients with Spondylodiscitis and Isolated Spinal Epidural Empyema Requiring Surgical Treatment

BACKGROUND

the successful treatment of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) depends on early detection of causative pathogens, which is commonly performed either via blood cultures, intraoperative specimens, and/or image-guided biopsies. We evaluated the diagnostic sensitivity of these three procedures and assessed how it is influenced by antibiotics.

METHODS

we retrospectively analyzed data from patients with SD and ISEE treated surgically at a neurosurgery university center in Germany between 2002 and 2021.

RESULTS

we included 208 patients (68 [23-90] years, 34.6% females, 68% SD). Pathogens were identified in 192 cases (92.3%), including 187 (97.4%) pyogenic and five (2.6%) non-pyogenic infections, with Gram-positive bacteria accounting for 86.6% (162 cases) and Gram-negative for 13.4% (25 cases) of the pyogenic infections. The diagnostic sensitivity was highest for intraoperative specimens at 77.9% (162/208, p = 0.012) and lowest for blood cultures at 57.2% (119/208) and computed tomography (CT)-guided biopsies at 55.7% (39/70). Blood cultures displayed the highest sensitivity in SD patients (SD: 91/142, 64.1% vs. ISEE: 28/66, 42.4%, p = 0.004), while intraoperative specimens were the most sensitive procedure in ISEE (SD: 102/142, 71.8% vs. ISEE: 59/66, 89.4%, p = 0.007). The diagnostic sensitivity was lower in SD patients with ongoing empiric antibiotic therapy (EAT) than in patients treated postoperatively with targeted antibiotic therapy (TAT) (EAT: 77/89, 86.5% vs. TAT: 53/53, 100%, p = 0.004), whereas no effect was observed in patients with ISEE (EAT: 47/51, 92.2% vs. TAT: 15/15, 100%, p = 0.567).

CONCLUSIONS

in our cohort, intraoperative specimens displayed the highest diagnostic sensitivity especially for ISEE, whereas blood cultures appear to be the most sensitive for SD. The sensitivity of these tests seems modifiable by preoperative EAT in patients with SD, but not in those with ISEE, underscoring the distinct differences between both pathologies.

Clinical phenotyping of spondylodiscitis and isolated spinal epidural empyema: a 20-year experience and cohort study

Background

The incidence of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been increasing in the last decades, but the distinct differences between both entities are poorly understood. We aimed to evaluate the clinical phenotypes and long-term outcomes of SD and ISEE in depth.

Methods

We performed a chart review and analyzed data from our cohorts of consecutive SD and ISEE patients who were treated and assessed in detail for demographic, clinical, imaging, laboratory, and microbiologic characteristics at a university neurosurgical center in Germany from 2002 to 2021. Between-group comparisons were performed to identify meaningful differences in both entities.

Results

We included 208 patients (72 females: age 75 [75 32-90] y vs. 136 males: 65 [23-87] y, median [interquartile range], p < 0.001), of which 142 (68.3%) had SD and 66 (31.7%) had ISEE. Patients with SD were older than ISEE (ISEE: 62 y vs. SD: 70 y, p = 0.001). While SD was more common in males than females (males: n = 101, 71.1% vs. females: n = 41, 28.9%, p < 0.001), there was no sex-related difference in ISEE (males: n = 35, 53.0% vs. females: n = 31, 47.0%, p = 0.71). Obesity was more frequent in ISEE than in SD (ISEE: n = 29, 43.9% vs. SD: n = 37, 26.1%, p = 0.016). However, there were no between-group differences in rates of diabetes and immunodeficiency. In the entire study population, a causative pathogen was identified in 192 (92.3%) patients, with methicillin-susceptible staphylococcus aureus being most frequent (n = 100, 52.1%) and being more frequent in ISEE than SD (ISEE: n = 43, 65.2% vs. SD: n = 57, 40.1%, p = 0.003). SD and ISEE occurred most frequently in the lumbar spine, with no between-group differences (ISEE: n = 25, 37.9% vs. SD: n = 65, 45.8%, p = 0.297). Primary infectious sources were identified in 145 patients (69.7%) and among this skin infection was most common in both entities (ISEE: n = 14, 31.8% vs. SD: n = 25, 24.8%, p = 0.418). Furthermore, epidural administration was more frequent the primary cause of infection in ISEE than SD (ISEE: n = 12, 27.3% vs. SD: n = 5, 4.9%, p < 0.001). The most common surgical procedure in SD was instrumentation (n = 87, 61%) and in ISEE abscess evacuation (n = 63, 95%). Patients with ISEE displayed lower in-hospital complication rates compared to SD for sepsis (ISEE: n = 12, 18.2% vs. SD: n = 94, 66.2%, p < 0.001), septic embolism (ISEE: n = 4/48 cases, 8.3% vs. SD: n = 52/117 cases, 44.4%, p < 0.001), endocarditis (ISEE: n = 1/52 cases, 1.9% vs. SD: n = 23/125 cases, 18.4%, p = 0.003), relapse rate (ISEE: n = 4/46, 8.7% vs. SD: n = 27/92, 29.3%, p = 0.004), and disease-related mortality (ISEE: n = 1, 1.5% vs. SD: n = 11, 7.7%, p = 0.108). Patients with SD showed prolonged length of hospital stay (ISEE: 22 [15, 30] d vs. SD: 38 [29, 53] d, p < 0.001) and extended intensive care unit stay (ISEE: 0 [0, 4] d vs. SD: 3 [0, 12] d, p < 0.002).

Conclusions

Our 20-year experience and cohort analysis on the clinical management of SD and ISEE unveiled distinct clinical phenotypes and outcomes in both entities, with ISEE displaying a more favorable disease course with respect to complications and relapse rates as well as disease-related mortality.

Ruptured mycotic aneurysm of intercostal arteries associated with vertebral osteomyelitis: a case report

BACKGROUND

Here, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention.

CASE PRESENTATION

A 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient's right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications.

CONCLUSIONS

Intercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

Treatment Failure in Vertebral Osteomyelitis: Is it All About Staphylococcus aureus ?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim was to compare the influence of 2 common vertebral osteomyelitis (VO) causing pathogens on treatment failure within the first year of diagnosis.

SUMMARY OF BACKGROUND DATA

VO is mainly caused by Staphylococcus aureus (SA), while enterococci and streptococci (ENST) are also responsible for a significant proportion of VO, particularly in elderly patients. Data on VO caused by SA show a tendency for worse outcome, whereas data on VO caused by ENST are scarce. For this purpose, our study compares characteristics of patients with VO caused by SA or ENST in order to analyze risk factors for treatment failure.

METHODS

We conducted a retrospective monocentric study including VO patients from 2008 to 2020. Primary outcome was treatment failure defined as death or relapse within 1 year (T1). We compared patients diagnosed with VO caused by Staphylococcus aureus including MRSA to patients diagnosed with VO caused by Enterococcus and Streptococcus species, which were combined into one group. Polymicrobial infections were excluded. We employed multiple logistic regression analysis to adjust for confounding. To account for moderation, the model was repeated with an included interaction term.

RESULTS

Data of 130 VO patients (SA=95; ENST=35) were available at T1. Treatment failure occurred in 37% of SA patients and 23% of ENST patients. On multivariate analysis SA [odds ratio (OR): 3.12; 95% confidence interval (CI): 1.09-10.53; P =0.046], Charlson comorbidity index (OR: 1.31; 95% CI: 1.11-1.58; P =0.002) and infectious endocarditis (IE; OR: 4.29; 95% CI: 1.23-15.96; P =0.024) were identified as independent risk factors for treatment failure.

CONCLUSION

In our cohort every third patient with VO caused by SA or ENST dies within 1 year. Our findings indicate that patients with VO caused by SA, concomitant IE and/or a high Charlson comorbidity index score may be at elevated risk for treatment failure. These findings can be used to individualize patient care and to direct clinical surveillance. This could include echocardiography evaluating for the presence of IE in patients with VO caused by gram-positive pathogens.

First Case of Pyogenic Spondylodiscitis Caused by Gemella sanguinis

A 78-year-old man presented with back pain. Magnetic resonance imaging revealed marrow edema within the L4 and L5 vertebral bodies and a spinal epidural abscess in the spinal canal. The patient was considered to have pyogenic spondylodiscitis at the L4/L5 level. The Gram-positive cocci isolated from blood cultures were subsequently identified as Gemellasanguinis using matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS). Symptom improvement was achieved and the infection was eradicated with conservative treatment (treatment with ceftriaxone [CTRX] and minocycline [MINO]). We report the first case of G. sanguinis-associated pyogenic spondylodiscitis. MALDI-TOF MS was useful in identifying this uncommon bacterium.

A Severe Systemic Infection in a 14-Year-Old Boy That Took Place during the COVID-19 Pandemic

Introduction: Since March 2020, the COVID-19 pandemic has been a global talking point. Access to health care has become more difficult, and such an obstacle increase the risk of inadequate medical care, especially among paediatric patients. Case: This report describes the case of a previously healthy teenager who was staying home for 2 months due to a strict lockdown period in the COVID-19 pandemic and was admitted to hospital for fever, nausea and lumbar pain. He was diagnosed consecutively with meningitis, sepsis, paraspinal abscesses and endocarditis. Further investigation did not reveal any risk factors or immunodeficiency in the patient. Discussion: Sepsis is defined as the presence of systemic inflammatory response syndrome (SIRS) associated with a probable or documented infection. It is the leading cause of death from infection, especially if not recognized and treated quickly. Sepsis may lead to various complications, such as infective endocarditis, meningitis and abscesses. Although such complications may initially be latent, they can promote internal organ dysfunction and the possibility of their presence should be considered in any patient with systemic infection. Any child with a fever should be treated as one with the possibility of developing a severe infection. Conclusion: The presented case shows that even a previously healthy child staying in long-term home isolation can develop a severe infection with multiorgan complications, and the COVID-19 pandemic should not extend the diagnostic process in patients with symptoms of infection.

Vertebral Osteomyelitis and Infective Endocarditis Co-Infection

Many cases of vertebral osteomyelitis (VO) and infective endocarditis (IE) co-infection have been reported, and it has been recognized that attention should be paid to the possibility of both diseases co-existing during diagnosis and treatment. However, the incidence, clinical status, and outcomes of IE in patients with VO remain unclear. For this study, the eligibility criteria for patient recruitment included all cases of VO at the five medical university hospitals. Patients with a history of spinal surgery were excluded from this study. Echocardiography was routinely performed for all patients with VO. IE was diagnosed according to the modified Duke criteria for definite endocarditis. We analyzed demographic data, underlying conditions, clinical features, laboratory data, echocardiography, radiologic images, treatments, and outcomes. VO was diagnosed in 59 patients and IE was diagnosed in seven patients (12%). There were no significant differences in the clinical features, microorganisms, or radiographic status between the VO-IE co-infection and VO-only groups. In this study, using routine echocardiography for VO, the IE prevalence was 12%. The lack of specific clinical features and laboratory findings may hamper the diagnosis of IE. Therefore, clinicians are always required to suspect IE in patients with VO.

CT-Guided Needle Biopsy in Vertebral Osteomyelitis: Study of Factors That Could Influence in Culture Yield

OBJECTIVE

The aim of this study was to analyze which are the main factors that could influence the result of a CT guided biopsy in vertebral osteomyelitis (VO) patients.

METHODS

A single center retrospective observational study was performed including adult patients who had been diagnosed with VO and undergone CT guided needle biopsy from January 2010 to January 2020. Demographical features, concurrent diseases, laboratory findings, microbiological diagnosis, radiological data, medical complications, antibiotic exposure were compiled. Multivariate analysis was performed with a logistic regression comparing the patients depending on the culture result.

RESULTS

Seventy-seven patients were included in the study. Baseline characteristics were comparable between groups. Sample culture was positive in 43 cases (56%). Microorganism isolated were gram+(72%), gram-(14%), mycobacteria (7%) and fungi (7%). Delay in the procedure, antibiotic exposure and blood culture positivity were also similar among both groups. The biopsy results were not influenced by the CRP value, the presence of fever nor antibiotic exposure. The longer duration of back pain was associated to a lower probability of a positive culture.

CONCLUSIONS

In conclusion, our study displays an acceptable reliability of CT guided needle biopsy in VO patients, even in cases under antibiotic treatment. The presence of fever or CRP values did not predict a positive culture. Delay in diagnosis could impact negatively on culture yield.

[Common infectious challenges of the thoracic and lumbar spine : Spondylodiscitis and postoperative wound infection]

Spondylodiscitis and postoperative wound infections are the most frequent infectious diseases of the thoracic and lumbar spine. Every spinal surgeon will come into contact with such patients during his or her career. Knowledge particularly of the diagnostics, conservative and surgical treatment as well as microbiological considerations of antibiotic treatment are therefore of particular importance and are explained in this article.

Pyogenic and Non-Pyogenic Spinal Infections: Diagnosis and Treatment

Spinal infection (SI) is an infection of vertebral bodies, intervening disc, and/or adjoining para-spinal tissue. It represents less than 10 % of all skeletal infections. There are numerous factors that predispose to developing a SI. Due to the low specificity of signs, delayed diagnosis is common. Hence, SI may be associated with poor outcomes. Diagnosis of SI must be supported by clinicopathological and radiological findings. MRI is a reliable modality of choice. Treatment options vary according to the site of the infection, disease progression, neurology, presence of instability, and general condition of the subject. Conservative treatment (orthosis/ bed-rest + antibiotics) is recommended during the early course with no/ lesser degree of neurological involvement and to medically unfit patients. Nevertheless, when conservative measures alone fail, surgical interventions must be considered. The use of concomitant antimicrobial drugs intravenously during initial duration followed by oral administration is a necessity. Controversies exist regarding the optimal duration of antimicrobial therapy, yet never given less than six weeks. Heterogeneity in clinical picture and associated co-morbidities with a range of treatment modalities are available; however, a common applicable guideline for SI does not exist. Managing SI must be tailored on a case-to-case basis.

Spontaneous spondylodiscitis and endocarditis: interdisciplinary experience from a tertiary institutional case series and proposal of a treatment algorithm

Previously, the simultaneous presence of endocarditis (IE) has been reported in 3–30% of spondylodiscitis cases. The specific implications on therapy and outcome of a simultaneous presence of both diseases are not yet fully evaluated. Therefore, the aim of this study was to investigate the influence of a simultaneously present endocarditis on the course of therapy and outcome of spondylodiscitis. A prospective database analysis of 328 patients diagnosed with spontaneous spondylodiscitis (S) using statistical analysis with propensity score matching was conducted. Thirty-six patients (11.0%) were diagnosed with concurrent endocarditis (SIE) by means of transoesophageal echocardiography. In our cohort, the average age was 65.82 ± 4.12 years and 64.9% of patients were male. The incidence of prior cardiac or renal disease was significantly higher in the SIE group (coronary heart disease SIE n = 13/36 vs. S n = 57/292, p < 0.05 and chronic heart failure n = 11/36 vs. S n = 41/292, p < 0.05, chronic renal failure SIE n = 14/36 vs. S n = 55/292, p < 0.05). Complex interdisciplinary coordination and diagnostics lead to a significant delay in surgical intervention (S = 4.5 ± 4.5 days vs. SIE = 8.9 ± 9.5 days, p < 0.05). Mortality did not show statistically significant differences: S (13.4%) and SIE (19.1%). Time to diagnosis and treatment is a key to efficient treatment and patient safety. In order to counteract delayed therapy, we developed a novel therapy algorithm based on the analysis of treatment processes of the SIE group. We propose a clear therapy pathway to avoid frequently observed pitfalls and delays in diagnosis to improve patient care and outcome.

Best Practices: CT-Guided Percutaneous Sampling of Vertebral Discitis-Osteomyelitis and Technical Factors Maximizing Biopsy Yield

Vertebral discitis-osteomyelitis is an infection of the intervertebral disk and vertebral bodies that may extend to adjacent paraspinal and epidural soft tissues. Its incidence is increasing, likely because of improved treatments and increased life expectancy for patients with predisposing chronic disease and increased rates of IV drug use and intravascular intervention. Because blood cultures are frequently negative in patients with vertebral discitis-osteomyelitis, biopsy is often indicated to identify a causative microorganism for targeted antimicrobial therapy. The reported yield of CT-guided percutaneous sampling is 31-91%, which is lower than the reported yield of open biopsy of 76-91%. However, the less invasive approach may be favored given its relative safety and low cost. If paravertebral fluid collections are present, CT-guided aspiration should be performed. If aspiration is unsuccessful or no paravertebral fluid collections are present, CT-guided percutaneous biopsy should be performed, considering technical factors (e.g., anatomic approach, needle selection, and needle angulation) that may improve microbiologic yield. Although antimicrobial therapy should be withheld for 1-2 weeks before biopsy if clinically feasible, biopsy may still be performed without stopping antimicrobial therapy if needed. Because of the importance of targeted antimicrobial therapy, repeat biopsy should be considered after 72 hours if initial biopsy does not identify a pathogen.

Native Vertebral Osteomyelitis in Patients with Staphylococcus aureus Bacteremia

BACKGROUND

The purpose of the study was to assess the epidemiology, risk factors and outcomes of native vertebral osteomyelitis (NVO) in patients with Staphylococcus aureus bacteremia (SAB).

METHODS

A retrospective institutional review was conducted at Mayo Clinic, Minnesota. Patients aged ≥ 18 years with SAB who developed NVO from January 1, 2006 to December 31, 2020 were included and 3-month follow-up data were abstracted. Data pertaining to patient demographics, risk factors and outcomes were recorded using REDCap. A 1:2 nested case-control analysis was performed, and controls were matched according to age, sex and year of SAB diagnosis.

RESULTS

A total of 103 patients had NVO. A majority (60.2%) of patients was male, with a median age of 62.0 years. Thirty-one (30.1%) cases were caused by methicillin-resistant S. aureus (MRSA). The lumbar spine was most commonly (57.6%) and the most commonly reported comorbid conditions included diabetes mellitus (36.9%) and coronary artery disease (27.2%). Mortality at three-month follow-up was 18.6%. Nested case-control analysis revealed that injection drug use (IDU) and tobacco consumption were significant risk factors associated with NVO, while chronic hemodialysis and chronic liver disease (CLD) were associated with a decreased risk of NVO.

CONCLUSIONS

Atherosclerotic vascular disease was prominent in our contemporary cohort with NVO in the setting of SAB. Diabetes mellitus, tobacco consumption, older age and male sex likely contributed to this profile. Because IDU was associated with NVO, an increased number of cases should be anticipated among patients with IDU given the ongoing opioid epidemic in the United States.

Preclinical models of vertebral osteomyelitis and associated infections: Current models and recommendations for study design

Spine-related infections, such as vertebral osteomyelitis, discitis, or spondylitis, are rare diseases that mostly affect adults, and are usually of hematogenous origin. The incidence of this condition has gradually risen in recent years because of increases in spine-related surgery and hospital-acquired infections, an aging population, and intravenous (IV) drug use. Spine infections are most commonly caused by Staphylococcus aureus, while other systemic infections such as tuberculosis and brucellosis can also cause spondylitis. Various animal models of vertebral osteomyelitis and associated infections have been investigated in mouse, rat, chicken, rabbit, dog, and sheep models by hematogenous and direct inoculation in surgery, each with their strengths and limitations. This review is the first of its kind to concisely analyze the various existing animal models used to reproduce clinically relevant models of infection. Spine-related infection models must address the unique anatomy of the spine, the avascular nature of its structures and tissues and the consequences of tissue destruction such as spinal cord compression. Further investigation is necessary to elucidate the specific mechanisms of host-microbe response to inform antimicrobial therapy and administration techniques in a technically demanding body cavity. Small-animal models are not suitable for large instrumentation, and difficult IV access thwarts antibiotic administration. In contrast, large-animal models can be implanted with clinically relevant instrumentation and are resilient to repeat procedures to study postoperative infection. A canine model of infection offers a unique opportunity to design and investigate antimicrobial treatments through recruitment a rich population of canine patients, presenting with a natural disease that is suitable for randomized trials.

Spontaneous Pyogenic Spondylitis and Possible Infective Endocarditis Caused by Aggregatibacter actinomycetemcomitans

Aggregatibacter actinomycetemcomitans, an etiological agent associated with periodontitis, endocarditis, and other infections, has rarely been implicated in spondylitis. A 70-year-old man with aortic valve replacement presented with a 4-month history of lower back pain and was diagnosed with spondylitis. Prolonged incubation of blood cultures and a biopsy yielded A. actinomycetemcomitans. Concurrent infective endocarditis (IE) was probable considering the infectious organism and the patients' prosthetic valve. The patient was treated with ceftriaxone and recovered well. Pyogenic spondylitis with possible concurrent IE may be caused by A. actinomycetemcomitans. Extended incubation and repeated cultures should be considered if Haemophilus spp., Aggregatibacter spp, Cardiobacterium spp, Eikenella spp, and Kingella spp. (HACEK) infection is suspected.

Vertebral osteomyelitis as a hidden cause of persistent meningeal irritation in a patient with pneumococcal meningitis: A case report

RATIONALE

Pneumococcal meningitis generally develops from bacteremia and is often complicated by multiple organ infection.

PATIENT CONCERNS

A 62-year-old man with no previous medical history developed progressive disturbance of consciousness preceded by high-grade fever and headache for a few days.

DIAGNOSIS

The patient was diagnosed with pneumococcal meningitis based on meningeal irritation, polymorphonuclear cell-predominant pleocytosis of the cerebrospinal fluid (CSF) and a positive pneumococcal urinary antigen test at a different hospital. Despite the administration of meropenem and vancomycin, his consciousness worsened, and the patient was transferred to our hospital. Marked nuchal stiffness was noted. The patient showed a disturbance of consciousness, with a Glasgow Coma Scale score of E3V2M5. No significant cranial nerve palsy, motor weakness or sensory impairment was observed. CSF examination showed polynuclear cell-predominant pleocytosis of 755/μL. Transthoracic echocardiography revealed infectious endocarditis.

INTERVENTIONS

After the detection of penicillin-susceptible Streptococcus pneumoniae, the antibiotic regimen was changed to aminobenzylpenicillin 12 g/d and ceftriaxone 4 g/d, which improved the patient's consciousness and CSF findings. However, marked neck stiffness and neck pain persisted; we performed a systemic investigation that revealed cervical vertebral osteomyelitis and aortic aneurysm.

OUTCOMES

After surgical treatment, the patient achieved complete remission of both conditions.

LESSONS

We should consider vertebral osteomyelitis as a potential complication of meningitis when nuchal stiffness persists despite an improvement in meningitis.

Obesity in spontaneous spondylodiscitis: a relevant risk factor for severe disease courses

Spondylodiscitis is a serious and potentially life-threatening disease. Obesity is a risk factor for many infections, and its prevalence is increasing worldwide. Thus, the aim of this study was to describe characteristics of obese patients with spondylodiscitis and identify risk factors for a severe disease course in obese patients. Between December 2012 and June 2018, clinical records were screened for patients admitted for spondylodiscitis. The final analysis included 191 adult patients (mean age 64.6 ± 14.8 years). Patient data concerning demographics, comorbidities, surgical treatment, laboratory testing, and microbiological workup were analysed using an electronic database. Patients were grouped according to body mass index (BMI) as BMI ≥ 30 kg/m² or < 30 kg/m². Seventy-seven patients were classified as normal weight (BMI 18.5-24.9 kg/m²), 65 as preobese (BMI 25-29.9 kg/m²), and 49 as obese (BMI ≥ 30 kg/m²). Obese patients were younger, had a higher revision surgery rate, and showed higher rates of abscesses, neurological failure, and postoperative complications. A different bacterial spectrum dominated by staphylococci species was revealed (p = 0.019). Obese patients with diabetes mellitus had a significantly higher risk for spondylodiscitis (p = 0.002). The mortality rate was similar in both cohorts, as was the spondylodiscitis localisation. Obesity, especially when combined with diabetes mellitus, is associated with a higher proportion of Staphylococcus aureus infections and is a risk factor for a severe course of spondylodiscitis, including higher revision rates and sepsis, especially in younger patients.

The STAPH Score: A Predictor of Staphylococcus aureus as the Causative Microorganism of Native Vertebral Osteomyelitis

Background

Staphylococcus aureus (SA) is the most common causative microorganism in native vertebral osteomyelitis (NVO). Few studies have compared the clinical features of NVO due to SA (SA-NVO) and NVO due to other organisms (NSA-NVO). This study was conducted to validate a predictive score for SA-NVO to facilitate NVO treatment without broad-spectrum antimicrobial agents.

Methods

This retrospective study compared the clinical features of patients with SA-NVO and NSA-NVO who were diagnosed from 2004 to 2019. Univariate associations were assessed using χ ², Fisher's exact, or Mann-Whitney U test. Multivariable analysis was conducted using logistic regression. The optimal age cutoff point was determined by classification and regression tree analysis.

Results

Among 155 NVO patients, 98 (63.2%) had a microbiologically confirmed diagnosis: 40 (25.8%) with SA-NVO and 58 (37.4%) with NSA-NVO. Six predictors, either independently associated with SA-NVO or clinically relevant, were used to develop the STAPH prediction score: atopic dermatitis (Skin) (3 points); recent Trauma (2 points); Age < 67 years (1 point); Abscess (1 point); central venous Port catheter (2 points); and History of puncture (2 points). In a receiver operating characteristic analysis, the area under the curve was 0.84 (95% confidence interval, 0.76-0.91). The best cutoff point was 3. A score ≥3 had a sensitivity, specificity, positive predictive value, and negative predictive value of 58%, 84%, 84%, and 73%, respectively.

Conclusions

The STAPH score has relatively high specificity for use by clinicians to predict SA as the causative microorganism in patients with NVO until results of a confirmatory culture are available.

Status Quo of Diagnostic Procedures and Treatment of Inpatients with Infective Endocarditis at the Department of General Medicine at a University Hospital in a Suburban City in Japan: A Single-Hospital-Based Retrospective Study

Background

Our hospital’s department of general medicine is often involved in the diagnosis and treatment of diseases that are considered by other hospitals or other departments in our hospital to be difficult to diagnose correctly.

Objective

The aim of this study was to clarify how patients with infective endocarditis (IE) being admitted to our hospital’s department of general medicine were examined and treated and to elucidate their prognosis compared with patients admitted to other departments.

Materials and Methods

Inpatients of Saga University Hospital with definite IE from September 2007 to August 2017 were divided into 2 groups: those admitted to the general medicine department (the GM group) and those admitted to other departments (the non-GM group).

Results

Seventy-four patients were included; 17 (23%) were admitted to the general medicine department. In the GM group, the percentage of patients diagnosed with definite or suspected IE was lower (0% vs 32%, p=0.008), as was the rate of patients with echocardiographic findings that fulfilled the major modified Duke’s criteria (71% vs 98%, p≤0.001), preadmission. The GM group had higher percentages of patients with back or joint pain (41% vs 9%, p=0.001) and complications, including pyogenic spondylitis (35% vs 2%, p≤0.001), deep-seated abscesses (24% vs 5%, p=0.024), pyogenic arthritis (18% vs 0%, p=0.001), and glomerulonephritis (77% vs 37%, p=0.004) than did the non-GM group. Mortality within 30 days of admission to our hospital (12% vs 14%, p=0.753) and overall in-hospital mortality (12% vs 18%, p=0.570) did not significantly differ.

Conclusion

The general medicine department could have accurately diagnosed IE, given appropriate treatments, and obtained similar prognoses to those of IE patients treated by other departments, including cardiology and cardiovascular surgery, even in patients for whom diagnosing IE was more difficult or who had less typical echocardiographic findings preadmission.

CT-guided discitis-osteomyelitis biopsies: needle gauge and microbiology results

PURPOSE

To compare the microbiology results and needle gauge for CT-guided biopsies of suspected discitis-osteomyelitis.

METHODS

All CT-guided biopsies performed for suspected discitis-osteomyelitis at our institution between 2002 and 2019 were reviewed. Biopsy location, needle type and gauge, microbiology, pathology, and clinical and imaging follow-up were obtained through chart review. Yield, sensitivity, specificity, and accuracy were calculated. A pairwise analysis of different needle gauges was also performed with calculations of odds ratios. Naïve Bayes predictive modeling was performed.

RESULTS

241 (age: 59 ± 18 years; 88 [35%] F, 162 [65%] M) biopsies were performed. There were 3 (1%) 11 gauge (G), and 13 (5%) 12-G biopsies; 23 (10%) 13-G biopsies; 75 (31%) 14-G biopsies; and 90 (37%) 16-G, 33 (14%) 18-G, and 4 (2%) 20 G biopsies. True disease status (presence of infection) was determined via either pathology findings (205, 86%) or clinical and imaging follow-up (36, 14%). The most common true positive pathogen was Staphylococcus aureus (31, 33%). Overall biopsy yield, sensitivity, specificity, and accuracy were 39%, 56%, 89%, and 66%, respectively. Pooled biopsy yield, sensitivity, specificity, and accuracy was 56%, 69%, 71%, and 69% for 11-13-G needles and 36%, 53%, 91%, and 65% for 14-20-G needles, respectively, with an odds ratio between the two groups of 2.29 (P = 0.021). Pooled biopsy yield, sensitivity, specificity, and accuracy was 48%, 63%, 85%, and 68% for 11-14-G needles and 32%, 49%, 91%, and 64% for 16-20-G needles, respectively, with an odds ratio between the two groups of 2.02 (P = 0.0086).

CONCLUSION

The use of a larger inner bore diameter/lower gauge biopsy needle may increase the likelihood of culturing the causative microorganism for CT-guided biopsies of discitis-osteomyelitis.

Change of Pyogenic and Tuberculous Spondylitis between 2007 and 2016 Year : A Nationwide Study

Objective

We attempted to compare the incidence of pyogenic spondylitis (PS) and tuberculous spondylitis (TS) between 2007 and 2016. Furthermore, we investigated the patients who underwent surgery in 2016 compared to that in 2007.

Methods

We used a nationwide database managed by the Korean National Health Insurance Service (NHIS) in 2007 and 2016. Total 9655 patients with a newly diagnosis of PS or TS were enrolled in PS or TS group. Among them, 1721 patients underwent either fusion or decompression surgery. We analyzed demographic distribution of patients according to gender and age and year of diagnosis.

Results

Comparing between 2007 and 2016, the incidence of PS has increased in 2016 than in 2007 (4874 vs. 2431, p<0.0001). Conversely, declination of incidence of TS was discovered in 2016 compared to 2007 (594 vs. 1756, p<0.0001). Females showed predominance over males regarding both PS and TS (5228 vs. 4427, p<0.0001). Among them, the number of PS patients who underwent surgery increased significantly in 2016 relative to that in 2007 (979 vs. 592, p<0.0001).

Conclusion

This nationwide study suggests that PS may increase and TS may decrease in Korea. In addition, demand for surgery regarding PS may increase.

Infective endocarditis in patients with pyogenic spondylodiscitis: implications for diagnosis and therapy

OBJECTIVEThe incidence of patients with pyogenic spinal infection is increasing. In addition to treatment of the spinal infection, early diagnosis of and therapy for coexisting infections, especially infective endocarditis (IE), is an important issue. The aim of this study was to evaluate the proportion of coexisting IE and the value of routine transesophageal echocardiography (TEE) in the management of these patients.METHODSThe medical history, laboratory data, radiographic findings, treatment modalities, and results of TEE of patients admitted between 2007 and 2017 were analyzed.RESULTSDuring the abovementioned period, 110 of 255 total patients underwent TEE for detection of IE. The detection rate of IE between those patients undergoing and not undergoing TEE was 33% and 3%, respectively (p < 0.0001). Thirty-six percent of patients with IE needed cardiac surgical intervention because of severe valve destruction. Chronic renal failure, heart failure, septic condition at admission, and preexisting heart condition were significantly associated with coexisting IE. The mortality rate in patients with IE was significantly higher than in patients without IE (22% vs 3%, p = 0.002).CONCLUSIONSTEE should be performed routinely in all patients with spondylodiscitis.

Spondylodiscitis complicating infective endocarditis

OBJECTIVE

The primary objective was to assess the characteristics and prognosis of pyogenic spondylodiscitis (PS) in patients with infective endocarditis (IE). The secondary objectives were to assess the factors associated with occurrence of PS.

METHODS

Prospective case-control bi-centre study of 1755 patients with definite IE with (n=150) or without (n=1605) PS. Clinical, microbiological and prognostic variables were recorded.

RESULTS

Patients with PS were older (mean age 69.7±18 vs 66.2±14; p=0.004) and had more arterial hypertension (48% vs 34.5%; p<0.001) and autoimmune disease (5% vs 2%; p=0.03) than patients without PS. The lumbar vertebrae were the most frequently involved (84 patients, 66%), especially L4-L5. Neurological symptoms were observed in 59% of patients. Enterococci and Streptococcus gallolyticus were more frequent (24% vs 12% and 24% vs 11%; p<0001, respectively) in the PS group. The diagnosis of PS was based on contrast-enhanced MRI in 92 patients, bone CT in 88 patients and ¹⁸F-FDG PET/CT in 56 patients. In-hospital (16% vs 13.5%, p=0.38) and 1-year (21% vs 22%, p=0.82) mortalities did not differ between patients with or without PS.

CONCLUSIONS

PS is a frequent complication of IE (8.5% of IE), is observed in older hypertensive patients with enterococcal or S. gallolyticus IE, and has a similar prognosis than other forms of IE. Since PS is associated with specific management, multimodality imaging including MRI, CT and PET/CT should be used for early diagnosis of this complication of endocarditis.

Vertebral osteomyelitis: Clinical, microbiological and radiological characteristics of 116 patients

INTRODUCTION/OBJECTIVES

To describe the clinical, radiological and microbiological characteristics of vertebral osteomyelitis patients, analysing the factors that played a role on their outcome.

PATIENTS AND METHODS

Single-centre retrospective observational study including patients diagnosed with vertebral osteomyelitis, based on the combination of clinical presentation with either a definitive bacteriological diagnosis and/or imaging studies.

RESULTS

116 adult patients were included with a mean age of 62.75 (14.98) years. Males predominated (68.10%). Eighteen patients (15.51%) were immunosuppressed. The most frequent symptom was back pain (99.14%) followed by fever, which was detected in 45 patients (38.79%). Puncture-aspiration or biopsy was performed in 84 patients (72.10%) and its culture was positive in 48 samples (57.14%). Gram positive species predominated (73.86%) on cultures, followed by Gram negative (12.5%), mycobacteria (10.23%) and fungi (3.41%). No microorganism was identified in 28 patients (24.14%). On imaging, most of the patients (92.24%) had paravertebral or epidural abscess. 63 cases (54.31%) showed vertebral destruction and 39 (33.62%) cord compression. Twenty-two patients (18.97%) required further surgical procedures and 13 (11.21%) died.

CONCLUSIONS

The average patient is middle aged (often male) with a history of subacute back pain, sometimes presenting fever and/or neurological damage on diagnosis. Acute phase reactants are frequently raised. Diabetes mellitus, endocarditis and immunosuppressed patients may have the worst chance of a good outcome, therefore these patients should be more carefully managed (always try to obtain an imaging-guided biopsy, correct antibiotic treatment, and a functional and clinical follow-up).

Microbial Etiology of Pyogenic Vertebral Osteomyelitis According to Patient Characteristics

Background

It is difficult to select an appropriate empirical antibiotic treatment regimen for patients with culture-negative pyogenic vertebral osteomyelitis (PVO). Having knowledge of the distribution of microorganisms according to patient characteristics can help clinicians make informed choices regarding empirical antibiotics. The aim of this study was to determine the microbial distribution among individuals with PVO according to their demographic and clinical characteristics.

Methods

We reviewed the medical records of patients admitted to our hospital with culture-confirmed PVO between January 2005 and December 2017 and collected data on demographics, underlying diseases, and radiographic and microbiological results. Statistical analysis was performed to identify associations between specific bacteria and specific patient characteristics.

Results

A total of 586 patients were included in the study. The prevalence of Staphylococcus aureus infections was higher in young patients than in old patients, while gram-negative bacterial infections and Enterococcus were more prevalent in older patients. Gram-negative bacterial infections were more common in women than in men (32.1% vs 16.4%; P < .05), in patients with cirrhosis than in those without (32.7% vs 21.1%; P < .05), and in patients with a solid tumor than in those without (31.0% vs 20.7%; P < .05). Methicillin-resistant S. aureus infections were more prevalent in patients with chronic renal disease than in those without (34.4% vs 14.7%; P < .05).

Conclusions

The microbial etiology of PVO varies according to patient characteristics. Patient characteristics should thus be considered when choosing empirical antibiotics in patients with culture-negative PVO.

A retrospective cohort study evaluating correlates of deep tissue infections among patients enrolled in opioid agonist treatment using administrative data in Ontario, Canada

Objective

The objective of this study was to evaluate the relationship between individual characteristics and deep tissue infections in patients enrolled in opioid agonist treatment in Ontario, Canada.

Methods

A retrospective cohort study was conducted on patients in opioid agonist treatment between January 1, 2011, and December 31, 2015 in Ontario, Canada. Patients were identified using data from the Ontario Health Insurance Plan Database, and the Ontario Drug Benefit Plan Database. We identified other study variables including all-cause mortality using data from the Registered Persons Database. Encrypted patient identifiers were used to link across databases. Logistic regression models were used to measure potential correlates of deep tissue infections.

Results

An increase in the incidence of deep tissue infections was observed between 2011 and 2016 for patients on opioid agonist treatment. Additionally, age, sex, positive HIV diagnosis, and all-cause mortality was correlated with deep tissue infection in our study population.

Conclusion

The study indicates factors that are associated with deep tissue infections in the opioid use disorder population and can be used to identify opportunities to reduce the incidence of new infections.

Progressive flaccid paraparesis with albuminocytologic dissociation: It's not always Gullain-Barre syndrome

CONTEXT

Spondylodiscitis, or vertebral osteomyelitis, is an unusual infection of the vertebral bodies and intervertebral discs that can occasionally present with neurological signs.

FINDINGS

We present a patient with subacute flaccid paraparesis with associated albuminocytologic dissociation who was eventually diagnosed with spondylodiscitis.

CONCLUSION

The case presented depicts a diagnostic difficulty encountered in clinical practice: Albuminocytologic dissociation in CSF is not always attributed to Guillain-Barre syndrome and other possible causes such as obstructive spinal cord lesions must always be considered.

Incidence and Characteristics of Osteoarticular Infections in Patients With Infective Endocarditis

Osteoarticular infections (OAIs) in the setting of infective endocarditis (IE) are uncommon. Although morbidity and mortality have been widely studied, details of the characteristics of patients with concurrent IE and OAI are limited. Therefore, the purpose of this study was to determine the (1) incidence, (2) mortality, (3) clinical features, and (4) microbiological profiles of OAIs in the setting of IE. A retrospective review was conducted of 1280 IE cases at a large academic institution between 2009 and 2015. Patients were categorized according to the following OAI types: spondylodiskitis, large joint septic arthritis, other site infections, or multiple affected joints. Inpatient mortality rates, clinical findings, and microbiological characteristics were compared between OAI types. Overall, the incidence of OAI among IE patients was 6.8% (n=87). The in-hospital mortality rate was 9.2% (n=8) and was not significantly associated with OAI type (P=.801). Eighteen patients had multiple affected joints resulting in a total of 114 infected sites. Of these, 39% (n=44) were spondylodiskitis, 29% (n=33) were large joint septic arthritis, and 32% (n=37) were infections of smaller joints. Back pain was most common among patients with spondylodiskitis (P<.001), whereas fever and general fatigue were most common with septic arthritis (P<.001). Of the available bone/ joint cultures, 69% were positive. Overall, Staphylococcus aureus was the most common IE pathogen in patients with both IE and OAI (63%). Clinicians should maintain a high suspicion for OAI in patients with IE caused by Staphylococcus aureus, particularly spondylodiskitis among those presenting with back pain. [Orthopedics 2020; 43(1):24-29.].

Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults

PURPOSE

Diagnosis of spondylodiscitis (SD) may be challenging due to the nonspecific clinical and laboratory findings and the need to perform various diagnostic tests including serologic, imaging, and microbiological examinations. Homogeneous management of SD diagnosis through international, multidisciplinary guidance would improve the sensitivity of diagnosis and lead to better patient outcome.

METHODS

An expert specialist team, comprising nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), neuroradiologists appointed by the European Society of Neuroradiology (ESNR), and infectious diseases specialists appointed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), reviewed the literature from January 2006 to December 2015 and proposed 20 consensus statements in answer to clinical questions regarding SD diagnosis. The statements were graded by level of evidence level according to the 2011 Oxford Centre for Evidence-based Medicine criteria and included in this consensus document for the diagnosis of SD in adults. The consensus statements are the result of literature review according to PICO (P:population/patients, I:intervention/indicator, C:comparator/control, O:outcome) criteria. Evidence-based recommendations on the management of adult patients with SD, with particular attention to radiologic and nuclear medicine diagnosis, were proposed after a systematic review of the literature in the areas of nuclear medicine, radiology, infectious diseases, and microbiology.

RESULTS

A diagnostic flow chart was developed based on the 20 consensus statements, scored by level of evidence according to the Oxford Centre for Evidence-based Medicine criteria.

CONCLUSIONS

This consensus document was developed with a final diagnostic flow chart for SD diagnosis as an aid for professionals in many fields, especially nuclear medicine physicians, radiologists, and orthopaedic and infectious diseases specialists.

Outcomes and risk factors for spontaneous spondylodiscitis: Case series and meta-analysis of the literature

Despite recent improvements in surgical and antimicrobial therapies, few generally applicable guidelines exist for spondylodiscitis management. We reviewed a consecutive series of patients as well as the past 18 years of the literature and analyzed outcomes for either conservative or surgical treatment. We analyzed a consecutive series of adults with spontaneous spondylodiscitis treated at our institution over the last 6 years. We analyzed predictors for neurological deficits, vertebral collapse, and surgical treatment. We also performed a meta-analysis of the literature between 2000 and 2018, stratifying the results between surgical and conservative treatment outcomes. A younger age at diagnosis, cervical location, tubercular infection, coexistence of morbidities, and vertebral collapse were predictors of surgical intervention. Cervical spondylodiscitis, vertebral collapse, and epidural collection were associated with a higher risk of developing neurological deficits, while tubercular spondylodiscitis was associated with a higher risk of vertebral collapse. Based on the current literature, conservative treatment has success rates similar to those of surgical treatment but lower complication and mortality rates. In cases without an absolute indication for surgery, a conservative approach should be considered as the first-line treatment. A closer diagnostic and clinical follow-up should be recommended in patients with cervical tract or tubercular spondylodiscitis because of the higher risk of developing bone collapse and neurological deficits.

Case report: right-sided native endocarditis presenting with multiple abscess formations [care compliant]

INTRODUCTION

Right-sided native endocarditis is a difficult case with fewer cardiac symptoms and fewer classic signs of cutaneous vascular lesions compared with left-sided endocarditis.

PATIENT CONCERNS

A 68-year-old Taiwanese man with a history of gouty arthritis, hyperlipidemia, and adrenal insufficiency presented to our ED and complained dyspnea and low back pain for 1 month.

DIAGNOSIS ASSESSMENT

The PE showed bilateral crackles on chest auscultation and a palpable fluctuant mass over the anterior chest wall. The chest and abdominal CT scan showed multiple abscess formations involving pulmonary, sternal, and paraspinal areas. The TEE being performed and an oscillating mass over the anterior and septal leaflets of the tricuspid valve and moderate tricuspid regurgitation.

INTERVENTIONS

Only pharmacologic treatment without surgical interventions.

OUTCOMES

Deceased, patient expired on day 4 after ED visit.

CONCLUSION

This case arose as a sequela of staphylococcal endocarditis associated with persistent bacteremia and immunological dysregulation. The diagnosis of right-sided endocarditis is easily missing, multidisciplinary approach should be triggered as soon as possible, which might lead to a better outcome. Right-sided IE is still an important public health issue in southern Taiwan.

Selection of an appropriate empiric antibiotic regimen in hematogenous vertebral osteomyelitis

Background

Empiric antibiotic therapy for suspected hematogenous vertebral osteomyelitis (HVO) should be initiated immediately in seriously ill patients and may be required in those with negative microbiological results. The aim of this study was to inform the appropriate selection of empiric antibiotic regimens for the treatment of suspected HVO by analyzing antimicrobial susceptibility of isolated bacteria from microbiologically proven HVO.

Method

We conducted a retrospective chart review of adult patients with microbiologically proven HVO in five tertiary-care hospitals over a 7-year period. The appropriateness of empiric antibiotic regimens was assessed based on the antibiotic susceptibility profiles of isolated bacteria.

Results

In total, 358 cases of microbiologically proven HVO were identified. The main causative pathogens identified were methicillin-susceptible Staphylococcus aureus (33.5%), followed by methicillin-resistant S. aureus (MRSA) (24.9%), Enterobacteriaceae (19.3%), and Streptococcus species (11.7%). Extended spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and anaerobes accounted for only 1.7% and 1.4%, respectively, of the causative pathogens. Overall, 73.5% of isolated pathogens were susceptible to levofloxacin plus rifampicin, 71.2% to levofloxacin plus clindamycin, and 64.5% to amoxicillin-clavulanate plus ciprofloxacin. The susceptibility to these oral combinations was lower in cases of healthcare-associated HVO (52.6%, 49.6%, and 37.6%, respectively) than in cases of community-acquired HVO (85.8%, 84.0%, and 80.4%, respectively). Vancomycin combined with ciprofloxacin, ceftriaxone, ceftazidime, or cefepime was similarly appropriate (susceptibility rates of 93.0%, 94.1%, 95.8%, and 95.8%, respectively).

Conclusions

Based on our susceptibility data, vancomycin combined with a broad-spectrum cephalosporin or fluoroquinolone may be appropriate for empiric treatment of HVO. Fluoroquinolone-based oral combinations may be not appropriate due to frequent resistance to these agents, especially in cases of healthcare-associated HVO.

Treatment algorithm for spontaneous spinal infections: A review of the literature

Background:

Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management.

Methods:

A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus.

Results:

Literature reveals that on the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of physical, radiological, and microbiological examinations. Microbiological culture samples can be obtained by a percutaneous computed tomography-guided procedure or by an open surgical biopsy. When possible, the samples should be harvested before antibiotic treatment is started. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and failure of conservative treatment.

Conclusion:

A multidisciplinary approach involving both a spinal surgeon and an infectious disease specialist is necessary to better define the treatment strategy. Based on literature findings, a treatment algorithm for the diagnosis and management of primary spinal infections is proposed.