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Lv H, Liao S, Shi Z, Guo Y, Zhou J, Chen H, Luo F, Xu J, Zhang Z, Zhang Z. Application of metagenomic next-generation sequencing for rapid molecular identification in spinal infection diagnosis. Front Cell Infect Microbiol 2024; 14:1382635. [PMID: 39011516 PMCID: PMC11247381 DOI: 10.3389/fcimb.2024.1382635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/10/2024] [Indexed: 07/17/2024] Open
Abstract
Objective This study aimed to determine the sensitivity and specificity of metagenomic next-generation sequencing (mNGS) for detecting pathogens in spinal infections and to identify the differences in the diagnostic performance between mNGS and targeted next-generation sequencing (tNGS). Methods A total of 76 consecutive patients with suspected spinal infections who underwent mNGS, culture, and histopathological examinations were retrospectively studied. The final diagnosis of the patient was determined by combining the clinical treatment results, pathological examinations, imaging changes and laboratory indicators. The sensitivity and specificity of mNGS and culture were determined. Results The difference between the two detection rates was statistically significant (p < 0.001), with mNGS exhibiting a significantly higher detection rate (77.6% versus 18.4%). The average diagnosis time of mNGS was significantly shorter than that of bacterial culture (p < 0.001, 1.65 versus 3.07 days). The sensitivity and accuracy of mNGS were significantly higher than that of the culture group (p < 0.001, 82.3% versus 17.5%; 75% versus 27.6%), whereas the specificity of mNGS (42.9%) was lower than that of the culture group (p > 0.05, 42.9% versus 76.9%). The sensitivity, specificity, accuracy, and positive predictive value (PPV) of pus were higher than those of tissue samples for mNGS, whereas for culture, the sensitivity, specificity, accuracy, and PPV of tissue samples were higher than those of pus. tNGS demonstrated higher sensitivity and accuracy in diagnosing tuberculosis (TB) than mNGS (80% versus 50%; 87.5% versus 68.8%). Conclusion mNGS for spinal infection demonstrated better diagnostic value in developing an antibiotic regimen earlier, and it is recommended to prioritize pus samples for testing through mNGS. Moreover, tNGS outperformed other methods for diagnosing spinal TB and identifying antibiotic-resistance genes in drug-resistant TB.
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Affiliation(s)
- Hui Lv
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
- Department of Orthopaedic, Southwest Hospital, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Sheng Liao
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
| | - Zhenzhen Shi
- Department of Medecine, Dinfectome Inc., Nanjing, Jiangsu, China
| | - Yuan Guo
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
| | - JianHong Zhou
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
| | - Hui Chen
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
| | - Fei Luo
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
- Department of Orthopaedic, Southwest Hospital, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - JianZhong Xu
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
- Department of Orthopaedic, Southwest Hospital, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - ZhongRong Zhang
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
- Department of Orthopaedic, Southwest Hospital, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - ZeHua Zhang
- Department of Spine Surgery, Jiangbei Branch of Southwest Hospital, 958th Hospital of the PLA Army, Chongqing, China
- Department of Orthopaedic, Southwest Hospital, The First Affiliated Hospital of Army Medical University, Chongqing, China
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Dai G, Li S, Yin C, Sun Y, Hou J, Luan L, Liu C, Wang Z, Cao Z, Wang T. Culture-negative versus culture-positive in pyogenic spondylitis and analysis of risk factors for relapse. Br J Neurosurg 2024; 38:527-531. [PMID: 33683182 DOI: 10.1080/02688697.2021.1896677] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study aims to compare and analyze the clinical features, diagnosis, treatment and prognosis of culture-negative and culture-positive primary pyogenic spondylitis. METHODS In a retrospective analysis, 202 cases of adult primary pyogenic spondylitis with complete clinical data in our hospital from January 2013 to January 2020 were divided into two groups according to bacterial culture results: culture negative (n = 126) and culture positive (n = 76). We compare the clinical characteristics, diagnosis, treatment and prognosis of patients with different culture results. RESULTS The culture positive rate was 37.62% (76/202). There were no significant differences in age, gender, affected segment, spinal abscess, diabetes mellitus, course of disease, surgery, recurrence, and follow-up time between the two groups (p>.05). There were statistically significant differences in hospital admission erythrocyte sedimentation rate (ESR), admission C-reactive protein (CRP), admission white blood cell (WBC) count, discharge ESR, discharge CRP, ESR decline rate, CRP (p<.05). There were statistically significant differences in the rate of decline, hospitalization days, and body temperature ≥38 °C (p<.05). Higher CRP levels on admission, antibiotic treatment time <6 weeks, and body temperature ≥ 38 °C are independent risk factors for infection recurrence. CONCLUSIONS The culture-negative group's admission WBC, admission ESR, admission CRP, discharge ESR, discharge CRP, ESR decline rate, CRP decline rate, and hospital stay were lower than the culture positive group, the difference was statistically significant (p<.05). The independent risk factors for infection recurrence are higher CRP levels in hospital admission, antibiotic treatment time <6 weeks, and body temperature ≥ 38 °C.
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Affiliation(s)
- Guohua Dai
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shuzhong Li
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuqiang Yin
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuanliang Sun
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianwen Hou
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Liangrui Luan
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chenjing Liu
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhichao Wang
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhenlu Cao
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ting Wang
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
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George AJ, Santhanagopal S, Mohan MM, Lal JV, Basappa M, Thomas JC, Jeevo J. Spondylodiscitis: A Diagnostic and Management Dilemma. Cureus 2024; 16:e58284. [PMID: 38752024 PMCID: PMC11094521 DOI: 10.7759/cureus.58284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2024] [Indexed: 05/18/2024] Open
Abstract
Aims Spondylodiscitis (SpD), a debilitating infective condition of the spine, mandates early diagnosis and institution of appropriate therapy, for which accurate microbiology and histological evaluation of the affected tissue is vital. The objectives of the study were to assess the correlation between clinical and magnetic resonance imaging (MRI) findings with histopathology (HPE) and microbiology (MB) in clinically diagnosed spondylodiscitis. Settings and design This was a prospective study of 34 consecutive patients reporting at the outpatient department of a tertiary hospital with clinical and imaging features of SpD, who underwent image-guided/surgical biopsy of lesions. Methods and material The provisional diagnosis of SpD in all patients was made on the combined basis of clinical profile and MRI Spine findings. Tissue samples in all patients, obtained by either open surgery or CT-guided biopsy, were subjected to HPE and MB analysis. Results SpD has a bimodal age distribution with the majority of patients being males in the fourth to fifth decades. Only raised erythrocyte sedimentation rate (ESR) was consistently seen amongst laboratory parameters, with leucocytosis being added pointer towards pyogenic etiology. MRI remained the imaging modality of choice for SpD but was not dependable for etiologic differentiation. On HPE and MB evaluations, 24 patients (71%) had findings consistent with infective SpD, while combined results augmented etiologic confirmation for 28 patients (82.4%). HPE was more sensitive than traditional MB methods to determine etiology in SpD, but the addition of the GeneXpert (Cepheid, Sunnyvale, California, United States) technique improved the MB positivity rate, especially in patients with tubercular SpD. Six patients (17.6%) with both negative HPE and MB results were categorized as 'Non-specific' SpD. Conclusions SpD poses a challenge to determine the etiology for the administration of specific antimicrobial therapy. A stratified standard institutional approach needs adoption to systematically evaluate SpD patients by having a high index of clinical suspicion, early imaging, followed by tissue biopsy for HPE and MB. Despite efforts to reach a diagnosis, a subset of patients without conclusive etiologic agent identification would remain as 'Non-specific', needing empiric antibiotic treatment based on clinico-radiologic profile.
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Affiliation(s)
- Akhshay J George
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
| | | | - Madan M Mohan
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
| | - Jaya V Lal
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
| | | | - Johann C Thomas
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
| | - Jerin Jeevo
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
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Wang J, Li Z, Chi X, Chen Y, Wang H, Wang X, Cui K, Wang Q, Lu T, Zheng J, Zhang Q, Hao Y. Development of a Diagnostic Model for Differentiating Tuberculous Spondylitis and Pyogenic Spondylitis With MRI: A Multicenter Retrospective Observational Study. Spine (Phila Pa 1976) 2024; 49:34-45. [PMID: 37796171 PMCID: PMC10702692 DOI: 10.1097/brs.0000000000004848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/02/2023] [Indexed: 10/06/2023]
Abstract
STUDY DESIGN Multicenter retrospective observational study. OBJECTIVE This study aimed to distinguish tuberculous spondylitis (TS) from pyogenic spondylitis (PS) using magnetic resonance imaging (MRI). Further, a novel diagnostic model for differential diagnosis was developed. SUMMARY OF BACKGROUND DATA TS and PS are the two most common spinal infections. Distinguishing between these types clinically is challenging. Delayed diagnosis can lead to deficits or kyphosis. Currently, there is a lack of radiology-based diagnostic models for TS and PS. METHODS We obtained radiologic images from MRI imaging of patients with TS and PS and applied the least absolute shrinkage and selection operator regression to select the optimal features for a predictive model. Predictive models were built using multiple logistic regression analysis. Clinical utility was determined using decision curve analysis, and internal validation was performed using bootstrap resampling. RESULTS A total of 201 patients with TS (n=105) or PS (n=96) were enrolled. We identified significant differences in MRI features between both groups. We found that noncontiguous multivertebral and single-vertebral body involvement were common in TS and PS, respectively. Vertebral bone lesions were more severe in the TS group than in the PS group (Z=-4.553, P <0.001). The patients in the TS group were also more prone to vertebral intraosseous, epidural, and paraspinal abscesses ( P <0.001). A total of 8 predictors were included in the diagnostic model. Analysis of the calibration curve and area under the receiver operating characteristic curve suggested that the model was well-calibrated with high prediction accuracy. CONCLUSIONS This is the largest study comparing MRI features in TS and PS and the first to develop an MRI-based nomogram, which may help clinicians distinguish between TS and PS.
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Affiliation(s)
- Jin Wang
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhaoxin Li
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiansu Chi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yungang Chen
- Department of Spinal Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Huaxin Wang
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | | | - Kaiying Cui
- Department of Spinal Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Qing Wang
- Department of Orthopedics, Shandong Public Health Clinical Center Affiliated to Shandong University, Jinan, China
| | - Tongxin Lu
- Department of Orthopedics, Shandong Public Health Clinical Center Affiliated to Shandong University, Jinan, China
| | - Jianhu Zheng
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Qiang Zhang
- Department of Orthopedics, Shandong Public Health Clinical Center Affiliated to Shandong University, Jinan, China
| | - Yanke Hao
- Department of Spinal Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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Pichler L, Li Z, Khakzad T, Perka C, Pumberger M, Schömig F. Microbial spectrum, patient-specific factors, and diagnostics in implant-related postoperative spondylodiscitis. Bone Jt Open 2023; 4:832-838. [PMID: 37918440 PMCID: PMC10622184 DOI: 10.1302/2633-1462.411.bjo-2023-0087.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023] Open
Abstract
Aims Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date. Methods Patients treated for IPOS from January 2006 to December 2020 were included. Patient demographics, parameters upon admission and discharge, radiological imaging, and microbiological results were retrieved from medical records. CT and MRI were analyzed for epidural, paravertebral, and intervertebral abscess formation, vertebral destruction, and endplate involvement. Pathogens were identified by CT-guided or intraoperative biopsy, intraoperative tissue sampling, or implant sonication. Results A total of 32 cases of IPOS with a mean patient age of 68.7 years (37.6 to 84.1) were included. Diabetes, age > 60 years, and history of infection were identified as risk factors. Patient presentation upon admission included a mean body temperature of 36.7°C (36.1 to 38.0), back pain at rest (mean visual analogue scale (VAS) mean 5/10) and when mobile (mean VAS 6/10), as well as elevated levels of CRP (mean 76.8 mg/l (0.4 to 202.9)) and white blood cell count (mean 9.2 units/nl (2.6 to 32.8)). Pathogens were identified by CT-guided or conventional biopsy, intraoperative tissue sampling, or sonication, and Gram-positive cocci presented as the most common among them. Antibiotic therapy was established in all cases with pathogen-specific treatment in 23 (71.9%) subjects. Overall 27 (84.4%) patients received treatment by debridement, decompression, and fusion of the affected segment. Conclusion Cases of IPOS are rare and share similarities with spontaneous spondylodiscitis. While procedures such as CT-guided biopsy and sonication are valuable tools in the diagnosis of IPOS, MRI and intraoperative tissue sampling remain the gold standard. Research on known principles of PJI such as implant retention versus implant exchange need to be expanded to the field of spine surgery.
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Affiliation(s)
- Lorenz Pichler
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Zhao Li
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Thilo Khakzad
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Friederike Schömig
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
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Ziarko TP, Walter N, Schindler M, Alt V, Rupp M, Lang S. Risk Factors for the In-Hospital Mortality in Pyogenic Vertebral Osteomyelitis: A Cross-Sectional Study on 9753 Patients. J Clin Med 2023; 12:4805. [PMID: 37510920 PMCID: PMC10381366 DOI: 10.3390/jcm12144805] [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: 06/22/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Pyogenic vertebral osteomyelitis represents a clinical challenge associated with significant morbidity and mortality. The aim of this study was to analyze potential risk factors for the in-hospital mortality of vertebral osteomyelitis (VO) patients. METHODS Based on the International Classification of Diseases, 10th Revision (ICD-10) codes for VO ("M46.2-", "M46.3-", and "M46.4-") data for total case numbers, secondary diagnoses, and numbers of in-hospital deaths were extracted from the Institute for the Hospital Remuneration System (InEK GmbH). Odds ratios (OR) for death were calculated for several secondary diseases and factors of interest. RESULTS Despite age, certain comorbidities were found to be strongly associated with increased mortality risk: Heart failure (OR = 2.80; 95% CI 2.45 to 3.20; p < 0.01), chronic kidney disease (OR = 1.83; 95% CI 1.57 to 2.13; p < 0.01), and diabetes with complications (OR = 1.86; 95% CI 1.46 to 2.38; p < 0.01). Among the complications, acute liver failure showed the highest risk for in-hospital mortality (OR = 42.41; 95% CI 23.47 to 76.62; p < 0.01). Additionally, stage III kidney failure (OR = 9.81; 95% CI 7.96 to 12.08; p < 0.01), sepsis (OR = 5.94; 95% CI 5.02 to 7.03; p < 0.01), acute respiratory failure (OR = 5.31; 95% CI 4.61 to 6.12; p < 0.01), and systemic inflammatory response syndrome (SIRS) (OR = 5.19; 95% CI 3.69 to 5.19; p < 0.01) were associated with in-hospital mortality. When analyzing the influence of pathogens, documented infection with Pseudomonas aeruginosa had the highest risk for mortality (OR = 2.74; 95% CI 2.07 to 3.63; p < 0.01), followed by Streptococci, Escherichia coli, and Staphylococcus aureus infections. CONCLUSIONS An early assessment of individual patient risk factors may be beneficial in the care and treatment of VO to help reduce the risks of mortality. These findings emphasize the importance of closely monitoring VO patients with chronic organ diseases, early detection and treatment of sepsis, and tailored empirical antibiotic therapy. The identification of specific pathogens and antibiotic susceptibility testing should be prioritized to improve patient outcomes in this high-risk population.
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Affiliation(s)
- Tomasz Piotr Ziarko
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Nike Walter
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Department for Psychosomatic Medicine, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Melanie Schindler
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Volker Alt
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Siegmund Lang
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
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Lang S, Walter N, Schindler M, Baertl S, Szymski D, Loibl M, Alt V, Rupp M. The Epidemiology of Spondylodiscitis in Germany: A Descriptive Report of Incidence Rates, Pathogens, In-Hospital Mortality, and Hospital Stays between 2010 and 2020. J Clin Med 2023; 12:jcm12103373. [PMID: 37240479 DOI: 10.3390/jcm12103373] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/20/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Spondylodiscitis can lead to significant morbidity and mortality. Understanding its up-to-date epidemiological characteristics and trends is important to improve patient care. METHODS This study analyzed trends in the incidence rate of spondylodiscitis cases in Germany between 2010 and 2020, as well as the pathogens, in-hospital mortality rate, and length of hospital stay. Data were obtained from the Federal Statistical Office and the Institute for the Hospital Remuneration System database. The ICD-10 codes "M46.2-", "M46.3-" and "M46.4-" were evaluated. RESULTS The incidence rate of spondylodiscitis increased to 14.4/100,000 inhabitants, with 59.6% cases occurring in patients 70 years or older and affecting mainly the lumbar spine (56.2%). Absolute case numbers increased from 6886 by 41.6% to 9753 in 2020 (IIR = 1.39, 95% CI 0.62-3.08). Staphylococci and Escherichia coli were the most coded pathogens. The proportion of resistant pathogens was 12.9%. In-hospital mortality rates increased to a maximum of 64.7/1000 patients in 2020, intensive care unit treatment was documented in 2697 (27.7%) cases, and the length of stay per case was 22.3 days. CONCLUSION The sharply increasing incidence and in-hospital mortality rate of spondylodiscitis highlights the need for patient-centered therapy to improve patient outcomes, especially in the geriatric, frail population, which is prone to infectious diseases.
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Affiliation(s)
- Siegmund Lang
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Nike Walter
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Melanie Schindler
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Susanne Baertl
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
- Centrum für Muskuloskeletale Chirurgie, Universitätsmedizin Berlin, Charitéplatz1, 10117 Berlin, Germany
| | - Dominik Szymski
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Markus Loibl
- Department of Spine Surgery, Schulthess Clinic Zurich, Lenghalde 2, 8008 Zurich, Switzerland
| | - Volker Alt
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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Chen KJ, Huang YC, Yao YC, Yang TC, Lin HH, Wang ST, Chang MC, Chou PH. Investigation of preoperative asymptomatic bacteriuria as a risk factor for postvertebroplasty infection. J Chin Med Assoc 2023; 86:233-239. [PMID: 36652570 DOI: 10.1097/jcma.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Postvertebroplasty infection (PVI) is a catastrophic complication after vertebroplasty (VP). Although the urinary tract has been considered as a source of infectious pathogens, whether asymptomatic bacteriuria (ASB) is a risk factors for PVI remains unknown. METHODS This retrospective study included 716 patients (207 males; 509 females) treated with VP for osteoporotic vertebral fractures in a single medical center between May 2015 and December 2019. Clinical symptoms, urinalysis results, and culture data were collected preoperatively to identify patients with ASB. The primary outcome was PVI at the index level during follow-up. Demographic data and laboratory test results were compared between the PVI and non-PVI groups. RESULTS The mean age of the cohort was 78.6 ± 9.6 (range, 63-106). The prevalence of ASB was 14.1%, with female predominance (63.4%). The overall PVI rate was 1.26% (9/716). The PVI group had more patients with ASB (4/9, 44.4%) than did the non-PVI group (97/707, 13.7%) (p = 0.027). The rate of ASB treatment was similar between the PVI and non-PVI groups (25% vs. 23.7%, respectively). No case of PVI was caused by the urine culture pathogen. Multivariate analysis identified the following risk factors for PVI: ASB (odds ratio [OR], 5.61; 95% CI, 1.14-27.66; p = 0.034), smoking (OR, 16.26; 95% CI, 2.58-102.65; p = 0.003), and malignancy (OR 7.27; 95% CI, 1.31-40.31; p = 0.023). CONCLUSION ASB was not uncommon among patients admitted for VP and should be considered a marker of relatively poor host immunity. Preoperative ASB, a history of malignancy, and smoking were identified as significant risk factors for PVI.
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Affiliation(s)
- Kuan-Jung Chen
- Department of Orthopedics, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yen-Chun Huang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yu-Cheng Yao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Tzu-Cheng Yang
- Department of Orthopedics, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hsi-Hsien Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shih-Tien Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Chau Chang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Hsin Chou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Schweizer TA, Andreoni F, Acevedo C, Scheier TC, Heggli I, Maggio EM, Eberhard N, Brugger SD, Dudli S, Zinkernagel AS. Intervertebral disc cell chondroptosis elicits neutrophil response in Staphylococcus aureus spondylodiscitis. Front Immunol 2022; 13:908211. [PMID: 35967370 PMCID: PMC9366608 DOI: 10.3389/fimmu.2022.908211] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
To understand the pathophysiology of spondylodiscitis due to Staphylococcus aureus, an emerging infectious disease of the intervertebral disc (IVD) and vertebral body with a high complication rate, we combined clinical insights and experimental approaches. Clinical data and histological material of nine patients suffering from S. aureus spondylodiscitis were retrospectively collected at a single center. To mirror the clinical findings experimentally, we developed a novel porcine ex vivo model mimicking acute S. aureus spondylodiscitis and assessed the interaction between S. aureus and IVD cells within their native environment. In addition, the inflammatory features underlying this interaction were assessed in primary human IVD cells. Finally, mirroring the clinical findings, we assessed primary human neutrophils for their ability to respond to secreted inflammatory modulators of IVD cells upon the S. aureus challenge. Acute S. aureus spondylodiscitis in patients was characterized by tissue necrosis and neutrophil infiltration. Additionally, the presence of empty IVD cells’ lacunae was observed. This was mirrored in the ex vivo porcine model, where S. aureus induced extensive IVD cell death, leading to empty lacunae. Concomitant engagement of the apoptotic and pyroptotic cell death pathways was observed in primary human IVD cells, resulting in cytokine release. Among the released cytokines, functionally intact neutrophil-priming as well as broad pro- and anti-inflammatory cytokines which are known for their involvement in IVD degeneration were found. In patients as well as ex vivo in a novel porcine model, S. aureus IVD infection caused IVD cell death, resulting in empty lacunae, which was accompanied by the release of inflammatory markers and recruitment of neutrophils. These findings offer valuable insights into the important role of inflammatory IVD cell death during spondylodiscitis and potential future therapeutic approaches.
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Affiliation(s)
- Tiziano A. Schweizer
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Federica Andreoni
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Claudio Acevedo
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas C. Scheier
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Irina Heggli
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Ewerton Marques Maggio
- Department of Pathology and Molecular Pathology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nadia Eberhard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Silvio D. Brugger
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | - Annelies S. Zinkernagel
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
- *Correspondence: Annelies S. Zinkernagel,
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10
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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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11
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Kafle G, Garg B, Mehta N, Sharma R, Singh U, Kandasamy D, Das P, Chowdhury B. Diagnostic yield of image-guided biopsy in patients with suspected infectious spondylodiscitis : a prospective study from a tuberculosis-endemic country. Bone Joint J 2022; 104-B:120-126. [PMID: 34969288 DOI: 10.1302/0301-620x.104b1.bjj-2021-0848.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB. METHODS A total of 284 patients with clinically and radiologically suspected infectious spondylodiscitis were prospectively recruited into the study. Image-guided biopsy of the vertebral lesion was performed and specimens were sent for various microbiological tests and histological examinations. The final diagnosis was determined using a composite reference standard based on clinical, radiological, serological, microbiological, and histological findings. The overall diagnostic yield of the biopsy, and that for each test, was calculated in light of the final diagnosis. RESULTS The final diagnosis was tuberculous spondylodiscitis in 250 patients (88%) and pyogenic spondylodiscitis in 22 (7.8%). Six (2.1%) had a noninfectious condition-mimicking infectious spondylodiscitis, and six (2.1%) had no definite diagnosis and improved without specific treatment. The diagnosis was made by image-guided biopsy in 152 patients (56%) with infectious spondylodiscitis. Biopsy was contributory in identifying 132/250 patients (53%) with tuberculous spondylodiscitis, and 20/22 patients (91%) with pyogenic spondylodiscitis. Histological examination was the most sensitive diagnostic modality, followed by Xpert MTB/RIF assay. CONCLUSION Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis. A combination of histological examination, Xpert MTB/RIF assay, bacterial culture, and sensitivity provides high diagnostic accuracy in a country in which TB is endemic. Cite this article: Bone Joint J 2022;104-B(1):120-126.
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Affiliation(s)
- Gokul Kafle
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Urvashi Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Buddhadev Chowdhury
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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12
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[Infections of the spine : Pyogenic spondylodiscitis and implant-associated vertebral osteomyelitis]. Unfallchirurg 2021; 124:489-504. [PMID: 33970304 DOI: 10.1007/s00113-021-01002-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
Pyogenic (unspecific) spondylodiscitis and implant-associated vertebral osteomyelitis (IAVO) are important diseases with the risk of neurological and septic complications. An early diagnosis is essential in which magnetic resonance imaging (MRI), histopathology and microbiological identification of the pathogen play key roles. The goals of conservative treatment in uncomplicated spondylodiscitis are antibiotic infection control and pain management. In the case of sepsis, neurological deficits, segmental instability or epidural abscesses surgical treatment of the infection with stabilization of the spine should be considered. In IAVO the formation of a mature biofilm represents the transition from acute to chronic infection. Acute infections can be treated by extensive debridement in combination with biofilm-active antibiotic treatment while retaining the implant. In chronic infections implant removal or exchange in combination with several weeks of antibiotic treatment is often necessary.
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13
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Ogawa Y, Masugi Y, Abe T, Yamazaki K, Ueno A, Fujii-Nishimura Y, Hori S, Yagi H, Abe Y, Kitago M, Sakamoto M. Three Distinct Stroma Types in Human Pancreatic Cancer Identified by Image Analysis of Fibroblast Subpopulations and Collagen. Clin Cancer Res 2020; 27:107-119. [PMID: 33046515 DOI: 10.1158/1078-0432.ccr-20-2298] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/03/2020] [Accepted: 10/06/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Cancer-associated fibroblasts have emerged to be highly heterogenous and can play multifaceted roles in dictating pancreatic ductal adenocarcinoma (PDAC) progression, immunosuppression, and therapeutic response, highlighting the need for a deeper understanding of stromal heterogeneity between patients and even within a single tumor. We hypothesized that image analysis of fibroblast subpopulations and collagen in PDAC tissues might guide stroma-based patient stratification to predict clinical outcomes and tumor characteristics. EXPERIMENTAL DESIGN A novel multiplex IHC-based image analysis system was established to digitally differentiate fibroblast subpopulations. Using whole-tissue slides from 215 treatment-naïve PDACs, we performed concurrent quantification of principal fibroblast subpopulations and collagen and defined three stroma types: collagen-rich stroma, fibroblast activation protein α (FAP)-dominant fibroblast-rich stroma, and α smooth muscle actin (ACTA2)-dominant fibroblast-rich stroma. These stroma types were assessed for the associations with cancer-specific survival by multivariable Cox regression analyses and with clinicopathologic factors, including CD8+ cell density. RESULTS FAP-dominant fibroblasts and ACTA2-dominant fibroblasts represented the principal distinct fibroblast subpopulations in tumor stroma. Stroma types were associated with patient survival, SMAD4 status, and transcriptome signatures. Compared with FAP-dominant fibroblast-rich stroma, collagen-rich stroma correlated with prolonged survival [HR, 0.57; 95% confidence interval (CI), 0.33-0.99], while ACTA2-dominant fibroblast-rich stroma exhibited poorer prognosis (HR, 1.65; 95% CI, 1.06-2.58). FAP-dominant fibroblast-rich stroma was additionally characterized by restricted CD8+ cell infiltrates and intense neutrophil infiltration. CONCLUSIONS This study identified three distinct stroma types differentially associated with survival, immunity, and molecular features, thereby underscoring the importance of stromal heterogeneity in subtyping pancreatic cancers and supporting the development of antistromal therapies.
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Affiliation(s)
- Yurina Ogawa
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Division of Diagnostic Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Tokiya Abe
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Ken Yamazaki
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Akihisa Ueno
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yoko Fujii-Nishimura
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Pathology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Michiie Sakamoto
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.
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14
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Paediatric spondylodiscitis: a 10-year single institution experience in management and clinical outcomes. Childs Nerv Syst 2020; 36:1049-1054. [PMID: 31848723 DOI: 10.1007/s00381-019-04470-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 12/04/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Discitis in the paediatric population poses diagnostic challenges due to non-specific presenting symptoms and difficulty with expressing pain in non-communicating children. Discitis remains a relatively rare condition in the paediatric population and previous reports are limited to small cohorts. In this article, we report our experience in management of discitis over a 10-year period and review the literature on this topic. METHODS We retrospectively reviewed cases of paediatric discitis/spondylodiscitis over a 10-year period between 2008 and 2018 managed in our regional paediatric neurosurgery unit. Relevant demographic information, microbiological data, blood investigation profile, antibiotic treatment duration and clinical outcomes were interrogated from clinical notes and electronic databases and further analysed. RESULTS Overall, 21 cases of paediatric discitis were identified from year 2008 to 2018 with a female to male ratio of 1.3:1. The mean age at presentation was 4.3 years (range 1 to 15 years). Overall, there were 19 cases of lumbosacral/lumbar, 1 thoracic and 1 cervical discitis. The mean duration of follow-up was 20 months (range 6 to 69 months). The most common presenting features were back pain and refusal to walk/sit or weight bear. Erythrocyte sedimentation rate (ESR) was found to be more sensitive than C-reactive protein (CRP) (sensitivity 78% versus 38%) in our cohort. Computer tomography (CT)-guided biopsy was performed in five cases and only one of these was positive (20%). All patients were treated with intravenous antibiotics with resolution of discitis. CONCLUSIONS Presentation of discitis in children can be non-specific and requires high index of suspicion. CT-guided biopsy in our cohort revealed a low rate of positive cultures. Despite negative blood cultures and CT-guided biopsy results, empirical intravenous antibiotics were effective in treating discitis successfully. In our cohort, low yield of CT-guided biopsy does not support its use on each case and this may be reserved for cases resistant to antimicrobial therapy or concerns regarding other pathology mimicking infection. Better understanding and awareness of this condition and its pathophysiology can lead to timely imaging, diagnosis and treatment.
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15
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Impact of MRI, CT, and Clinical Characteristics on Microbial Pathogen Detection Using CT-Guided Biopsy for Suspected Spondylodiscitis. J Clin Med 2019; 9:jcm9010032. [PMID: 31877797 PMCID: PMC7019669 DOI: 10.3390/jcm9010032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 01/23/2023] Open
Abstract
Spondylodiscitis accounts for 2–7% of osteomyelitis cases and is characterized by pain, systemic inflammation, and permanent neurological deficits. We aimed to identify imaging characteristics and clinical parameters to successfully predict microbiological pathogens by computed tomography (CT)-guided biopsy in suspected spondylodiscitis cases. Forty consecutive patients (mean age 65.1 years) with suspected spondylodiscitis underwent CT-guided biopsy. CT features (non-sclerotic endplate erosions (NSEs)), magnetic resonance criteria (paravertebral/epidural abscess (PA/EA) formation), and clinical data (C-reactive protein (CRP) > 50 mg/L) were assessed for their predictive potential. NSEs were detected in 6/11 (54.5%) and 1/29(3.4%) patients with positive and negative microbiology, respectively. PA and EA, respectively, were present in 7/11(63.6%) and 3/11 patients with positive microbiology and 7/29 (24.1%) and 2/29 patients with negative microbiology. CRP > 50 was observed in 7/11 (63.6%) and in 7/29 (24.1%) patients with positive and negative microbiology, respectively. Three double combinations possessed near-perfect specificity (PA + NSE, 100%; PA + CRP > 50, 96.6%; NSE + CRP > 50, 96.6%). The top three Youden indices included combinations with NSE. Since CT/magnetic resonance (MR) imaging and CRP are routinely used to evaluate spondylodiscitis, the presented diagnostic criteria and combinations can aid decision-making for biopsy.
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