Hot topics on vertebral osteomyelitis from the International Society of Antimicrobial Chemotherapy

Abstract

Vertebral osteomyelitis (VO), also known as spondylodiscitis, describes infections of the vertebrae and intervertebral discs. Discitis describes infection limited to the intervertebral discs; in clinical practice both discitis and VO can be regarded as different stages of a single entity. VO can be caused by bacteria, fungi and parasites The incidence of VO is increasing globally representing 3-5% of all osteomyelitis with an estimated incidence ranging from 4 to 24 per million per year. Increasing incidence has been attributed to a combination of improved diagnostics, increased healthcare associated infections, haemodialysis, indwelling catheters, intravenous drug use, spinal instrumentation, immunocompromised hosts and an ageing population [1]. If left untreated, VO can lead to irreversible spinal cord injury, deformity, neurologic deficits, septicaemia, and mortality (mortality rates ranges 4%-29%). VO is typically treated with antibiotics, but up to 40% to 50% of VO patients may eventually require surgical intervention [1-3] Despite advances in diagnostic modalities, medical and surgical care, there are still many controversial areas with regards to both diagnostic and therapeutic strategies in VO. In this review a number of 'hot topics' on VO were selected and reviewed by members of the Skin, Soft Tissue and Bone Infections Working Group of the International Society of Antimicrobial Chemotherapy (ISAC). This group includes international scientists, microbiology and infectious diseases clinicians and academics, whose aim is to advance the education and the science of infection management. This paper is an in-depth review of the current literature, providing a summary of the various aspects of VO and expert opinions and insights from the authors' own experience, highlighting areas for future study and research.

Management of vertebral osteomyelitis over an eight-year period: The UDIPROVE (UDIne PROtocol on VErtebral osteomyelitis)

“…In the literature, the sensitivity of image-guided biopsy in evaluated studies is about 40% (Sehn and Gilula, 2012 an infection that is very difficult to diagnose and treat, considering also the high rate of patients on antibiotic therapy at the time of diagnosis. The latter results in a low rate of positivity for BC and vertebral biopsy to determine the etiology of infection (Saeed et al, 2019). As reported in Figure 2, vertebral biopsy without antimicrobial discontinuation, according to the protocol, was associated with a high rate of negative results in the present study.…”

“…In this study population, failure of therapy for VO was observed in 19 patients (14.3%). The failure rate of patients treated for VO in most clinical studies has varied between 10% and 30% (Berbari et al, 2015;Ohtori et al, 2010;Hungenbach et al, 2013;Sehn and Gilula, 2012;Bhavan et al, 2010;Saeed et al, 2019;Kowalski et al, 2007;Zarrouk et al, 2007;Carragee, 1997;Nanni et al, 2012;Kim et al, 2009;Bassetti et al, 2017;Bakheet et al, 1998;Trecarichi et al, 2012;Heysell et al, 2013;Rissing, 1997). The therapeutic management of VO patients with treatment failure should be tailored to the suspected reason for failure.…”

Spinal Infections: An Update

“…Imaging should include the entire spine in order to assess the extension of the infection and to exclude any adjacent or skip lesions. Bone scintigraphy with technetium or labelled leucocytes is not routinely indicated because of their low sensitivity and specificity; gallium scans can have a role because if the result is negative, osteomyelitis is unlikely [45]. Newer tracers for bone scintigraphy such as indium-111 labeled (111In) biotin and streptavidin have been recently introduced [46].…”

“…Although there is a wide range of bacteria that can cause spinal infections, in most cases these infections are caused by a single microorganism rather than from multiple pathogens [45]. In those few poly-microbial infections (<10% of cases), the spine is usually affected through contiguous spread [30].…”

“…The optimal duration of antimicrobial therapy for spinal infections is highly debatable [45]. There is a wide variety of recommendations [1,44], with most authors recommending a period of four to six weeks [44], while others recommending a longer period of up to three months [68,74].…”