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Kolster M, Hönning A, Käckenmester W, Goy J, Ekkernkamp A, Spranger N. Applying the German S2k-Guideline for Diagnosis and Treatment of Spondylodiscitis-A 5-Year Retrospective Evaluation of Patients without Neurological Symptoms. Diagnostics (Basel) 2024; 14:1098. [PMID: 38893625 PMCID: PMC11172179 DOI: 10.3390/diagnostics14111098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Spondylodiscitis is a rather rare condition with an annual incidence of 1-7 per 100,000. Thus, empirical data on the treatment of this disease are limited. In 2020, the first German guideline for the diagnosis and treatment of spondylodiscitis was published. In a 5-year retrospective analysis, we examined the patient collective, the current diagnosis and treatment strategy, and the effect of Magnetic Resonance Imaging (MRI) diagnostics on therapeutic decisions of a consecutive monocentric cohort of 66 patients without neurological symptoms. The majority of the patients were male (55%) with a mean age of 74 years. Non-operative therapy was found to be associated with short-term treatment success in 54 (82%) of the patients. In 12 patients, who underwent surgical therapy, MRI diagnostics and clinical findings were equally important for the decision to perform a surgery. Patients treated operatively stayed for an average of 33.6 (±12.9) days in the hospital and thus significantly longer than non-operatively treated patients with 22.2 (±8.0) days. The in-house standard of care did not essentially deviate from the guideline's recommendations. Future research should address early detection of the need for surgical therapy, and immediate anti-infective treatment appropriate to the detected pathogen.
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Affiliation(s)
- Moritz Kolster
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, 12683 Berlin, Germany; (A.E.); (N.S.)
| | - Alexander Hönning
- Centre for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, 12683 Berlin, Germany; (A.H.); (W.K.)
| | - Wiebke Käckenmester
- Centre for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, 12683 Berlin, Germany; (A.H.); (W.K.)
| | - Janet Goy
- Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, 12683 Berlin, Germany;
| | - Axel Ekkernkamp
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, 12683 Berlin, Germany; (A.E.); (N.S.)
| | - Nikolai Spranger
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, 12683 Berlin, Germany; (A.E.); (N.S.)
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Wangaryattawanich P, Condos AM, Rath TJ. Bacterial and Viral Infectious Disease of the Spine. Magn Reson Imaging Clin N Am 2024; 32:313-333. [PMID: 38555143 DOI: 10.1016/j.mric.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Spinal infections are a diverse group of diseases affecting different compartments of the spine with variable clinical and imaging presentations. Diagnosis of spinal infections is based on a combination of clinical features, laboratory markers, and imaging studies. Imaging plays a pivotal role in the diagnosis and management of spinal infections. The characteristic imaging manifestations of bacterial and viral infections in the spine are discussed with key teaching points emphasized.
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Affiliation(s)
- Pattana Wangaryattawanich
- Department of Radiology, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195-7115, USA.
| | - Amy M Condos
- Department of Radiology, University of Washington School of Medicine, 2545 Northeast 85th Street Seattle, WA 98115, USA
| | - Tanya J Rath
- Neuroradiology Section, Department of Radiology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Peel TN, Cherk M, Yap K. Imaging in osteoarticular infection in adults. Clin Microbiol Infect 2024; 30:312-319. [PMID: 37940000 DOI: 10.1016/j.cmi.2023.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/18/2023] [Accepted: 11/02/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Osteoarticular infections are uncommon and required a multimodal approach for diagnosis. Imaging forms an important component of this multimodal approach. OBJECTIVES In this narrative review, we describe the different imaging modalities, features of osteoarticular infections present on these imaging approaches and recommendations for which imaging modality should be considered in different types of osteoarticular infections. SOURCES This narrative review was based on literature review from PubMed and was limited to bacterial infections in adult patients. CONTENT Imaging modalities include modalities that provide information on the anatomy or radionuclide imaging that provides information about the metabolic activity of the area of interest. Anatomical imaging includes plain radiographs (X-ray), computed tomography, and magnetic resonance imaging. Radionuclide approaches include three-phase bone scintigraphy, gallium scans, white blood cell scintigraphy, and 18F-fluorodeoxy-glucose positron emission tomography. The optimal radiological modality for diagnosis is influenced by multiple factors, including infection location, presence of metalware, timing of infection from any preceding surgery or fracture, antibiotic use, and patient comorbidities. Local availability of scanning modality, tracer supply, technical expertise, and patient access also influences choice. IMPLICATIONS A collaborative approach with imaging, pathology and clinical input in a multidisciplinary setting is paramount for the diagnosis of osteoarticular infections. Increasing research and improvements in technology will further improve the utility and accuracy of imaging approaches for imaging in osteoarticular infections.
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Affiliation(s)
- Trisha N Peel
- Department of Infectious Diseases, Monash University and Alfred Health, Melbourne, VIC, Australia.
| | - Martin Cherk
- Department of Nuclear Medicine & PET, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Kenneth Yap
- Department of Nuclear Medicine & PET, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia
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Amoxicillin Did Not Reduce Modic Change Edema in Patients With Chronic Low Back Pain: Subgroup Analyses of a Randomised Trial (the AIM Study). Spine (Phila Pa 1976) 2023; 48:147-154. [PMID: 36223435 PMCID: PMC9812422 DOI: 10.1097/brs.0000000000004513] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/05/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Exploratory subgroup analyses of a randomised trial [Antibiotics in Modic changes (AIM) study]. OBJECTIVE The aim was to assess the effect of amoxicillin versus placebo in reducing Modic change (MC) edema in patients with chronic low back pain. SUMMARY OF BACKGROUND DATA The AIM study showed a small, clinically insignificant effect of amoxicillin on pain-related disability in patients with chronic low back pain and MC type 1 (edema type) on magnetic resonance imaging (MRI). MATERIALS AND METHODS A total of 180 patients were randomised to receive 100 days of amoxicillin or placebo. MC edema was assessed on MRI at baseline and one-year follow-up. Per-protocol analyses were conducted in subgroups with MC edema on short tau inversion recovery (STIR) or T1/T2-weighted MRI at baseline. MC edema reductions (yes/no) in STIR and T1/T2 series were analyzed separately. The effect of amoxicillin in reducing MC edema was analyzed using logistic regression adjusted for prior disk surgery. To assess the effect of amoxicillin versus placebo within the group with the most abundant MC edema on STIR at baseline ("STIR3" group), we added age, STIR3 (yes/no), and STIR3×treatment group (interaction term) as independent variables and compared the marginal means (probabilities of edema reduction). RESULTS Compared to placebo, amoxicillin did not reduce MC edema on STIR (volume/intensity) in the total sample with edema on STIR at baseline (odds ratio 1.0, 95% CI: 0.5, 2.0; n=141) or within the STIR3 group (probability of edema reduction 0.69, 95% CI: 0.47, 0.92 with amoxicillin and 0.61, 95% CI: 0.43, 0.80 with placebo; n=41). Compared with placebo, amoxicillin did not reduce MC edema in T1/T2 series (volume of the type 1 part of MCs) (odds ratio: 1.0, 95% CI: 0.5, 2.3, n=104). Edema declined in >50% of patients in both treatment groups. CONCLUSIONS From baseline to one-year follow-up, amoxicillin did not reduce MC edema compared with placebo. LEVEL OF EVIDENCE 2.
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Lam JC, Stokes W. The Golden Grapes of Wrath - Staphylococcus aureus Bacteremia: A Clinical Review. Am J Med 2023; 136:19-26. [PMID: 36179908 DOI: 10.1016/j.amjmed.2022.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022]
Abstract
Staphylococcus aureus bacteremia is common and associated with fatality rates approximating 25%. We provide a brief overview of S. aureus bacteremia from a clinical and microbiological lens and review the relevant evidence and literature gaps in its management. Using a case-based approach, evidence and clinical judgement are meshed to highlight and justify the 5 core interventions that ought to be performed for all cases of S. aureus bacteremia: 1) appropriate anti-staphylococcal therapy, 2) screening echocardiography, 3) assessment for metastatic phenomena and source control, 4) decision on duration of antimicrobial therapy, and 5) Infectious Diseases consultation.
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Affiliation(s)
- John C Lam
- Division of Infectious Diseases, Department of Medicine, University of California Los Angeles.
| | - William Stokes
- Provincial Laboratory for Public Health, Alberta Precision Laboratories, Alberta, Canada; Department of Pathology and Laboratory Medicine; Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
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Baryeh K, Anazor F, Iyer S, Rajagopal T. Spondylodiscitis in adults: diagnosis and management. Br J Hosp Med (Lond) 2022; 83:1-9. [DOI: 10.12968/hmed.2021.0448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spondylodiscitis is often diagnosed late in its course because its symptoms are vague. The incidence in adults increases with age, being seen most commonly in men in their 50s and 60s, so the presence of other medical conditions or infections can make it more difficult to identify spondylodiscitis. Diagnosis is made based on clinical suspicion, raised levels of inflammatory markers, a positive blood or tissue biopsy culture and radiological findings. Once a diagnosis is confirmed, treatment must be started promptly. The mainstay of treatment is medical management, with antibiotics tailored to the relevant organism, as well as immobilisation. Where surgery is indicated, the aims are debridement of infected tissue, tissue sampling, neural decompression and stabilisation. Spondylodiscitis is associated with high rates of mortality and morbidity and should be treated promptly to ensure the best outcome.
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Affiliation(s)
- Kwaku Baryeh
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading, UK
- Department of Medical Education, West Middlesex University Hospital, Middlesex, UK
| | - Fitzgerald Anazor
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Shabnam Iyer
- Department of Microbiology, Royal Berkshire Hospital, Reading, UK
| | - Trichy Rajagopal
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading, UK
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Brooks CA, Mahajan S, Beresford R, Damodaran O, Pope R. Thoracic spondylodiscitis secondary to Klebsiella oxytoca urosepsis-a case report. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:54-61. [PMID: 35441097 PMCID: PMC8990402 DOI: 10.21037/jss-21-124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/27/2022] [Indexed: 06/14/2023]
Abstract
Spondylodiscitis is an insidious and infectious pathology of the spinal column attributable to pathogenic micro-organisms and occurs in a variety of contexts. These micro-organisms can be inoculated surgically or can metastasise from distant sites of infection. Klebsiella species are important community-acquired and nosocomial pathogens but are uncommonly implicated in spinal infection. Klebsiella oxytoca is more obscure than its generic relative Klebsiella pneumoniae and has only five times previously been reported in spondylodiscitis. It possesses the ability to acquire inducible and recombinant antibiotic resistance, especially in the hospital setting. We describe the case of an elderly man with complex urology and this rare sequela due to incomplete treatment of a K. oxytoca urinary infection. He developed sepsis that recurred after incomplete antibiosis and seeded to his thoracic spine causing overt spondylodiscitis. The infection fulminated and his spinal lesion deteriorated into acute spinal cord compression with neurological compromise, requiring surgical decompression, fixation and long-term antibiotics. This is a sixth documented instance of a rare spinal bacterial infection. We describe the relevant microbiology and pathology, neurosurgical considerations, and general practice points for clinicians. Our report is a novel illustration of the potentially catastrophic consequences of inadequately treated urosepsis and is a stark reminder of the importance of antimicrobial stewardship.
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Affiliation(s)
| | - Sameer Mahajan
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, Australia
| | - Rohan Beresford
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Concord, Australia
| | - Omprakash Damodaran
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, Australia
- Department of Neurosurgery, Nepean Hospital, Kingswood, Australia
| | - Raoul Pope
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, Australia
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Maamari J, Tande A, Diehn F, Tai DBG, Berbari E. Diagnosis of vertebral osteomyelitis. J Bone Jt Infect 2022; 7:23-32. [PMID: 35136714 PMCID: PMC8814828 DOI: 10.5194/jbji-7-23-2022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/06/2022] [Indexed: 12/19/2022] Open
Abstract
Native vertebral osteomyelitis (NVO) is a potentially fatal infection which
has seen a gradual increase in its incidence over the past decades. The
infection is insidious, presenting with symptoms of back pain. Fever is
present in about 60 % of patients. Prompt diagnosis of NVO is important to
prevent the development of complications. Numerous laboratory and imaging
tools can be deployed to accurately establish the diagnosis. Imaging
techniques such as magnetic resonance, nuclear imaging, and computed
tomography are essential in diagnosing NVO but can also be useful in
image-guided biopsies. Laboratory tools include routine blood tests,
inflammatory markers, and routine culture techniques of aspirated specimens.
Recent advances in molecular techniques can assist in identifying offending
pathogen(s). In this review, we detail the arsenal of techniques that can be
utilized to reach a diagnosis of NVO.
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Affiliation(s)
- Julian Maamari
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Aaron J. Tande
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Felix Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Elie F. Berbari
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
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Hecquet S, Verhoeven F, Aubry S, Prati C, Wendling D, Chirouze C, Bouiller K. Interest of Follow-Up Radiological Imaging in Patients with Pyogenic Vertebral Osteomyelitis. J Clin Med 2021; 10:jcm10122690. [PMID: 34207268 PMCID: PMC8233882 DOI: 10.3390/jcm10122690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
No recommendations are established for monitoring pyogenic vertebral osteomyelitis (PVO). Thus, the realization of systematic follow-up radiological imaging is controversial. The objective of this study was to evaluate the interest in follow-up radiological imaging in patients with PVO. We conducted a retrospective cohort analysis of patients with PVO who had both baseline and follow-up radiological imaging. We classified the follow-up images into two groups, improvement/stability, and deterioration, compared with the baseline data. For each patient, we compared their radiological imaging follow-up to their clinical-biological condition assessed at the same time. Eighty-six patients were included. The mean age was 68 years (±13). A total of 99 radiological imaging examinations at diagnosis and at follow-up were analyzed, 69 Magnetic Resonance Imaging (MRI), and 30 Computerized Tomography (CT scans). The mean delay between the follow-up radiological imaging and clinical evaluation was 2.8 +/- 2.1 months. Of the 36 patients with clinical and biological recovery, 24 patients (67%) had improved radiological imaging and 12 patients (34%) had radiological worsening (new abscesses (n = 4), extension of soft tissue infiltration (n = 2) and/or epiduritis (n = 2) or appearance of new locations (n = 1)). Among the 50 patients considered as unhealed, on the contrary, radiological imaging showed an improvement in imaging in 39 patients (78%) and a worsening in 11 patients (22%). Our study showed that there was no correlation between the clinical condition of patients and their follow-up radiological imaging in the context of PVO.
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Affiliation(s)
- Sophie Hecquet
- Department of Rheumatology, Besançon University Hospital, 25020 Besançon, France; (S.H.); (F.V.); (C.P.); (D.W.)
- PEPITE EA4267, FHU INCREASE, Bourgogne Franche-Comté University, UFR Santé, 25020 Besançon, France
| | - Frank Verhoeven
- Department of Rheumatology, Besançon University Hospital, 25020 Besançon, France; (S.H.); (F.V.); (C.P.); (D.W.)
- PEPITE EA4267, FHU INCREASE, Bourgogne Franche-Comté University, UFR Santé, 25020 Besançon, France
| | - Sébastien Aubry
- Department of Osteoarticular Radiology, Besançon University Hospital, 25020 Besançon, France;
| | - Clément Prati
- Department of Rheumatology, Besançon University Hospital, 25020 Besançon, France; (S.H.); (F.V.); (C.P.); (D.W.)
- PEPITE EA4267, FHU INCREASE, Bourgogne Franche-Comté University, UFR Santé, 25020 Besançon, France
| | - Daniel Wendling
- Department of Rheumatology, Besançon University Hospital, 25020 Besançon, France; (S.H.); (F.V.); (C.P.); (D.W.)
- EA 4266, EPILAB, Pathogens and Inflammation, Bourgogne Franche-Comté University, UFR Santé, 25020 Besançon, France
| | - Catherine Chirouze
- Department of Infectious Disease, Besançon University Hospital, 25020 Besançon, France;
- UMR CNRS, Bourgogne Franche-Comté University, 25020 Besançon, France
| | - Kévin Bouiller
- Department of Infectious Disease, Besançon University Hospital, 25020 Besançon, France;
- UMR CNRS, Bourgogne Franche-Comté University, 25020 Besançon, France
- Correspondence:
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