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"Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults"

current
Published: Clinical Infectious Diseases ; 2015 ; 61 : 26 -46

Abstract

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention.

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. This guideline was published in August of 2015 and is the most current version.

Recommendations

Recommendations for Clinical Diagnostics

I. When Should the Diagnosis of NVO Be Considered?

Recommendations

  1. Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and fever (strong, low).
  2. Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and elevated ESR or CRP (strong, low).
  3. Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and bloodstream infection or infective endocarditis (strong, low).
  4. Clinicians may consider the diagnosis of NVO in patients who present with fever and new neurologic symptoms with or without back pain (weak, low).
  5. Clinicians may consider the diagnosis of NVO in patients who present with new localized neck or back pain, following a recent episode of Staphylococcus aureus bloodstream infection (weak, low).

II. What Is the Appropriate Diagnostic Evaluation of Patients With Suspected NVO?

Recommendations

  1. We recommend performing a pertinent medical and motor/sensory neurologic examination in patients with suspected NVO (strong, low).
  2. We recommend obtaining bacterial (aerobic and anaerobic) blood cultures (2 sets) and baseline ESR and CRP in all patients with suspected NVO (strong, low).
  3. We recommend a spine MRI in patients with suspected NVO (strong, low).
  4. We suggest a combination spine gallium/Tc99 bone scan, or computed tomography scan or a positron emission tomography scan in patients with suspected NVO when MRI cannot be obtained (eg, implantable cardiac devices, cochlear implants, claustrophobia, or unavailability) (weak, low).
  5. We recommend obtaining blood cultures and serologic tests for Brucella species in patients with subacute NVO residing in endemic areas for brucellosis (strong, low).
  6. We suggest obtaining fungal blood cultures in patients with suspected NVO and at risk for fungal infection (epidemiologic risk or host risk factors) (weak, low).
  7. We suggest performing a purified protein derivative (PPD) test or obtaining an interferon-γ release assay in patients with subacute NVO and at risk for Mycobacterium tuberculosis NVO (ie, originating or residing in endemic regions or having risk factors) (weak, low).
  8. In patients with suspected NVO, evaluation by an infectious disease specialist and a spine surgeon may be considered (weak, low).

III. When Should an Image-Guided Aspiration Biopsy or Additional Workup Be Performed in Patients With NVO?

Recommendations

  1. We recommend an image-guided aspiration biopsy in patients with suspected NVO (based on clinical, laboratory, and imaging studies) when a microbiologic diagnosis for a known associated organism (S. aureus, Staphylococcus lugdunensis, and Brucella species) has not been established by blood cultures or serologic tests (strong, low).
  2. We advise against performing an image-guided aspiration biopsy in patients with S. aureus, S. lugdunensis, or Brucella species bloodstream infection suspected of having NVO based on clinical, laboratory, and imaging studies (strong, low).
  3. We advise against performing an image-guided aspiration biopsy in patients with suspected subacute NVO (high endemic setting) and strongly positive Brucella serology (strong, low).

IV. How Long Should Antimicrobial Therapy Be Withheld Prior to an Image-Guided Diagnostic Aspiration Biopsy in Patients With Suspected NVO?

Recommendations

  1. In patients with neurologic compromise with or without impending sepsis or hemodynamic instability, we recommend immediate surgical intervention and initiation of empiric antimicrobial therapy (strong, low).

V. When Is It Appropriate to Send Fungal, Mycobacterial, or Brucellar Cultures or Other Specialized Testing Following an Image-Guided Aspiration Biopsy in Patients With Suspected NVO?

Recommendations

  1. We suggest the addition of fungal, mycobacterial, or brucellar cultures on image-guided biopsy and aspiration specimens in patients with suspected NVO if epidemiologic, host risk factors, or characteristic radiologic clues are present (weak, low).
  2. We suggest the addition of fungal and mycobacterial cultures and bacterial nucleic acid amplification testing to appropriately stored specimens if aerobic and anaerobic bacterial cultures reveal no growth in patients with suspected NVO (weak, low).

VI. When Is It Appropriate to Send the Specimens for Pathologic Examination Following an Image-Guided Aspiration Biopsy in Patients With Suspected NVO?

Recommendations

  1. If adequate tissue can be safely obtained, pathologic specimens should be sent from all patients to help confirm a diagnosis of NVO and guide further diagnostic testing, especially in the setting of negative cultures (strong, low).

VII. What Is the Preferred Next Step in Patients With Nondiagnostic Image-Guided Aspiration Biopsy and Suspected NVO?

Recommendations

  1. In the absence of concomitant bloodstream infection, we recommend obtaining a second aspiration biopsy in patients with suspected NVO in whom the original image-guided aspiration biopsy specimen grew a skin contaminant (coagulase-negative staphylococci [except S. lugdunensis], Propionibacterium species, or diphtheroids) (strong, low).
  2. In patients with a nondiagnostic first image-guided aspiration biopsy and suspected NVO, further testing should be done to exclude difficult-to-grow organisms (eg, anaerobes, fungi, Brucella species, or mycobacteria) (strong, low).
  3. In patients with suspected NVO and a nondiagnostic image-guided aspiration biopsy and laboratory workup, we suggest either repeating a second image-guided aspiration biopsy, performing percutaneous endoscopic discectomy and drainage (PEDD), or proceeding with an open excisional biopsy (weak, low).

Recommendations for Clinical Therapy

VIII. When Should Empiric Antimicrobial Therapy Be Started in Patients With NVO?

Recommendations

  1. In patients with normal and stable neurologic examination and stable hemodynamics, we suggest holding empiric antimicrobial therapy until a microbiologic diagnosis is established (weak, low).
  2. In patients with hemodynamic instability, sepsis, septic shock, or severe or progressive neurologic symptoms, we suggest the initiation of empiric antimicrobial therapy in conjunction with an attempt at establishing a microbiologic diagnosis (weak, low).

IX. What Is the Optimal Duration of Antimicrobial Therapy in Patients With NVO?

Recommendations

  1. We recommend a total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy for most patients with bacterial NVO (strong, low).
  2. We recommend a total duration of 3 months of antimicrobial therapy for most patients with NVO due to Brucella species (strong, moderate).

X. What Are the Indications for a Surgical Intervention in Patients With NVO?

Recommendations

  1. We recommend surgical intervention in patients with progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate antimicrobial therapy (strong, low).
  2. We suggest surgical debridement with or without stabilization in patients with persistent or recurrent bloodstream infection (without alternative source) or worsening pain despite appropriate medical therapy (weak, low).
  3. We advise against surgical debridement and/or stabilization in patients who have worsening bony imaging findings at 4-6 weeks in the setting of improvement in clinical symptoms, physical examination, and inflammatory markers (weak, low).

Recommendations for Clinical Follow-up

XI. How Should Failure of Therapy Be Defined in Treated Patients With NVO?

Recommendation

  1. We suggest that persistent pain, residual neurologic deficits, elevated markers of systemic inflammation, or radiographic findings alone do not necessarily signify treatment failure in treated NVO patients (weak, low).

XII. What Is the Role of Systemic Inflammatory Markers and MRI in the Follow-up of Treated Patients With NVO?

Recommendations

  1. We suggest monitoring systemic inflammatory markers (ESR and or CRP) in patients with NVO after approximately 4 weeks of antimicrobial therapy, in conjunction with a clinical assessment (weak, low).
  2. We recommend against routinely ordering follow-up MRI in patients with NVO in whom a favorable clinical and laboratory response to antimicrobial therapy was observed (strong, low).
  3. We suggest performing a follow-up MRI to assess evolutionary changes of the epidural and paraspinal soft tissues in patients with NVO who are judged to have a poor clinical response to therapy (weak, low).

XIII. How Do You Approach a Patient With NVO and Suspected Treatment Failure?

Recommendations

  1. In patients with NVO and suspected treatment failure, we suggest obtaining markers of systemic inflammation (ESR and CRP). Unchanged or increasing values after 4 weeks of treatment should increase suspicion for treatment failure (weak, low).
  2. We recommend obtaining a follow-up MRI with emphasis on evolutionary changes in the paraspinal and epidural soft tissue findings in patients with NVO and suspected treatment failure (strong, low).
  3. In patients with NVO and clinical and radiographic evidence of treatment failure, we suggest obtaining additional tissue samples for microbiologic (bacteria, fungal, and mycobacterial) and histopathologic examination, either by image-guided aspiration biopsy or through surgical sampling (weak, very low).
  4. In patients with NVO and clinical and radiographic evidence of treatment failure, we suggest consultation with a spine surgeon and an infectious disease physician (weak, very low).

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