Spondylodiscitis in end-stage renal disease: a systematic review

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Discitis and osteomyelitis are seen in end-stage renal disease (ESRD) patients due to repeated vascular access for hemodialysis and urinary tract infections leading to recurrent bacteremia. Discitis and osteomyelitis are underdiagnosed due to the nonspecific initial presentation of back pain. In this article, we review the literature for better understanding of the problem and the importance of early diagnosis by primary care physicians and nephrologists. In addition, we discuss the decision-making, follow-up, management, and neurological outcomes.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A detailed PubMed search was performed using the following terms: “end stage renal disease (ESRD)” and “chronic renal failure (CRF),” combined with “spine infections,” “spondylodiscitis,” “discitis,” and “osteomyelitis.” Search results were limited to articles written in English, case reports, and case series from 1973 to 2012. Editorials, reviews, and commentaries were excluded. Only studies involving human patients were included. The authors also included 4 patients from their own patient population.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 30 articles met the inclusion criteria. Including the 4 patients from the authors’ patient population, 212 patients with spine infections and maintenance dialysis were identified. The patients’ ages ranged from 38 to 78 years. The duration of dialysis ranged from a few days to 16 years. The time from onset of back pain to diagnosis ranged from 3 days to 6 months. The most common causative organism was <jats:italic>Staphylococcus aureus</jats:italic>, followed by <jats:italic>Staphylococcus epidermidis</jats:italic> and gram-negative bacteria. Most of the patients were treated with antibiotics alone (76.8%), although surgery was indicated when patients presented with neurological deficits (p &lt; 0.011). Approximately one-quarter of the patients developed neurological deficits, with devastating consequences. Fever and neurological deficits at presentation, culture positive for methicillin-resistant <jats:italic>S. aureus</jats:italic>, and age &gt; 65 years were highly correlated with mortality in our analysis.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Several risk factors lead to failure of antibiotics and progression of disease in patients with ESRD. Challenges to diagnosis include vague presenting symptoms, co-existing destructive spondyloarthropathy, poor immune response, chronic elevations of inflammatory markers, and recurrent bacteremia. Infectious processes are more likely to cause permanent neurological deficits than transient deficits. The authors recommend close observation and serial imaging of these patients for early signs of neurological deficits. Any signs of disease progression will require aggressive surgical debridement.</jats:p></jats:sec>

Fatal neck pain in a patient on maintenance hemodialysis

“…SA bacteremia accounts for 38.4–50.9% of blood stream infections in HD patients 14 . According to a recent review, patients who developed IS had previous bacteremia of the same microorganism in 63% of cases, with SA being the most common pathogen agent (40.2%) 2 . In a retrospective review of 16 patients with cervical IS, MRSA was the primary pathogen in 31.2% of cases 3 …”

“…Blood cultures are the least invasive and easiest method for pathogen determination 7 . However, only 63–68% of patients have a positive blood culture 2,7 . The identification of the pathogen species should not delay broad‐spectrum antibiotic regimens for the treatment of common pathogens in spondylodiscitis in order to avoid fatal sepsis.…”

“…The evolution of our patient presenting with multiple comorbidities was unfortunately negative, probably due to the late diagnosis, and the patient died of severe septic shock despite a well‐conducted antimicrobial therapy. Old age, neurological deficits at presentation, and SA bacteremia are the main positive predictors of mortality in ESRD patients with IS 2 …”

“…Despite the increasing incidence of infectious spondylodiscitis (IS) and the advancement of diagnostic tools, IS is still underdiagnosed in end‐stage renal disease (ESRD) dialysis patients 2 . Furthermore, the ambiguity of symptoms often results in diagnostic delays 3 …”

Multidrug Resistance (MDR) and Collateral Sensitivity in Bacteria, with Special Attention to Genetic and Evolutionary Aspects and to the Perspectives of Antimicrobial Peptides—A Review

“…MRSA is the causative agent in many diseases worldwide [ 235 ]. This includes nosocomial infections like pneumonia [ 236 ], spondylodiscitis [ 237 ], colonization of burns and wounds [ 238 , 239 ], endocarditis [ 240 ], and renal problems [ 241 ], all of which have greatly increased hospital death tolls [ 242 ]. Methicillin-resistant S. aureus (MRSA), and S. epidermis isolates, from companion animals have been reviewed [ 243 , 244 ].…”