This article is more than 5 years old. Information may no longer be current.
New IDSA guidelines address gaps in vertebral osteomyelitis management
Click Here to Manage Email Alerts
The Infectious Diseases Society of America has published new guidelines in Clinical Infectious Diseases addressing research gaps in the diagnosis and management of native vertebral osteomyelitis.
A panel of nine infectious disease specialists, a spine orthopedic surgeon and a neuroradiologist wrote that native vertebral osteomyelitis (NVO), a condition in which bacteria enter the bloodstream and become embedded in a disc, is an uncommon infection that mainly occurs in older patients. According to a press release, two to six out of 100,000 patients develop NVO annually. This incidence is rising, however, due to an increase in susceptible populations, including IV drug users, patients on hemodialysis and immunocompromised hosts. Moreover, the ambiguous back and neck pain symptoms associated with NVO frequently deflect diagnosis.
“Back pain is so common — and usually not caused by infection — that diagnosis often is missed or delayed,” Elie F. Berbari, MD, associate chair of education for the division of infectious disease at Mayo Clinic College of Medicine in Rochester, Minnesota, said in the release. “The infection causes severe pain that often wakes the person at night and does not go away after pain management or rest. If that’s the case, the doctor needs to start considering that something else is going on, especially if the patient has a fever.”
Elie F. Berbari
The researchers gathered clinical evidence from PubMed/Medline, Cochrane Library, ClinicalTrials.gov and other sources published from 1970 to December 2014 to develop the recommendations. Under the new guidelines, a NVO diagnosis should be considered in patients who present with:
- new or worsening back or neck pain in addition to a fever, elevated erythrocyte sedimentation rates, elevated C-reactive protein values, a bloodstream infection or infective endocarditis;
- a fever and neurologic symptoms; and
- new localized back or neck pain following a recent Staphylococcus aureus episode.
The guidelines recommend examining at least two sets of blood cultures (aerobic and anaerobic), medical and neurologic assessments and MRI in patients suspected of having developed NVO. If NVO is still suspected after the MRI, a biopsy should be performed to confirm the infection and identify the bacteria. The most common bacteria that cause NVO are S. aureus, streptococcal species and enteric bacteria. Mycobacterium tuberculosis and Brucella are also common in endemic regions, according to the researchers.
Patients with hemodynamic instability, sepsis, septic shock or worsening neurologic symptoms should immediately receive empiric antimicrobial therapy, however, the panel was “not in favor of routine use.” Typically, 6 weeks of IV treatment is recommended after a microbiologic diagnosis is established, although some patients may be switched to oral antimicrobials with bioavailability.
Surgery may be needed in approximately 50% of patients with the infection, Berbari said in the release, if there are indications of neurologic compromise, major vertebral destruction, large epidural abscess formation, severe back pain or if therapy is unsuccessful. The researchers wrote that systemic inflammatory markers and radiographic results previously used to identify treatment failure may overestimate failure rates. Therefore, identifying infection through a microbiological diagnosis is the “most specific measure.”
If the patient’s conditions do not improve 4 weeks after therapy or surgery, a repeat MRI may be necessary. Patients with evidence of treatment failure should be seen by an ID physician.
“It’s important that the patient is seen by an expert familiar with the signs and symptoms of spine infections,” Steven K. Schmitt, MD, IDSA Board of Directors member and ID physician at Cleveland Clinic, said in the release. “Early diagnosis and appropriate management can prevent disability, so a high index of suspicion and early ID consultation are central to a good outcome.”
Disclosures : Berbari reports receiving honorarium from UpToDate. Schmitt reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Collapse
Click Here to Manage Email Alerts