View source for Native vertebral osteomyelitis (IDSA 2015)

Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, Hendershot EF, Holtom PD, Huddleston PM 3rd, Petermann GW, Osmon DR, Infectious Diseases Society of America. [https://doi.org/10.1093/cid/civ482 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults]. Clin Infect Dis. 2015 Sep 15;61(6):e26-46. doi: 10.1093/cid/civ482.

= Background =

* Native vertebral osteomyelitis (NVO) is usually from hematogenous seeding

= Diagnosis =

== Clinical Clues ==

* Suspect NVO in patients with new/worsening back/neck pain and any of the following:
** Fever
** Elevated ESR/CRP
** Bacteremia or infective endocarditis
** Following an episode of ''Staph.aureus'' bacteremia
* Suspect NVO in patients with new neurologic symptoms and fever, regardless of back pain

== Diagnostic Approach ==

* Neurologic exam
* Blood cultures x2 and baseline ESR/CRP
* Blood cultures and serology for ''Brucella'' for subacute NVO where it is endemic
** Spain and other countries of the Mediterranean basin, Latin America, the Middle East, parts of Africa, and Western Asia
* Fungal blood cultures if they are at risk
* TBST or IGRA if at risk for TB
* MRI spine as first-line diagnostic of choice
** Gallium/Tc99 bone scan, of CT, or PET are alternatives
* Consider involving surgery

== Biopsy ==

* Biopsy not needed if blood cultures grow ''S. aureus'', ''Staphylococcus lugdenensis'', or ''Brucella'' or ''Brucella'' serology is strongly positive
* Image-guided biopsy is recommended when a definitive organism has not been found
** Add fungal, mycobacterial, or brucellar cultures if there is suspicion. Can also do NAAT later, if the routine bacterial cultures are negative.
** Ideally also send a specimen for pathology
** Do ''not'' withhold antimicrobials if there is neurologic compromised
* If the biopsy is negative or equivocal, it should be repeated
** Test for anaerobes, fungi, ''Brucella'', mycobacteria
** Can consider discectomy and drainage or open excisional biopsy

= Management =

* If they are clinically stable with no neurologic compromise, then it is reasonable to withhold antimicrobials while attempting to establish a microbiological diagnosis
* Duration is '''at least 6 weeks''' of parenteral or highly bioavailable oral antimicrobial therapy
** Duration in ''Brucella'' is at least 3 months
* Surgical intervention is recommended if there is neurologic compromise or worsening despite antimicrobials
** This decision should ''not'' be based on worsening imaging when there is clinical improvement
* At 4 weeks, reassess clinically with a repeat ESR/CRP
** If it has halved, that is a good prognostic sign
** No need for routine repeat imaging

== Common Parenteral Antibiotics ==

{|
! Microorganism
! First-line
! Alternatives
! Comments
|-
| ''Staphylococcus'' spp, ox-susceptible
| Nafcillin or oxacillin 1.5-2 g IV q4-6h or continuous, or<br/>Cefazolin 1-2 IV q8h, or<br/>Ceftriaxone 2 g IV q24h
| Vanco 15-20 mg/kg IV q12h, or<br/>Dapto 6-8 mg/kg IV q24h, or<Br/>Linezolid 600 mg PO/IV/iv q12h, or<br/>Levofloxacin 500-750 mg PO q24h and rifampin 600 PO mg daily, or<br/>Clindamycin 600-900 mg IV q8h
| 6 weeks
|-
| ''Staphylococcus'' spp, ox-resistant
| Vanco 15-20 mg/kg IV q12h (consider loading dose)
| Dapto 6-8 mg/kg IV q24h, or<br/>Linezolid 600 mg PO/IV q12h, or<br/>Levofloxacin 500-750 mg PO q24h and rifampin 600 mg PO daily
| 6 weeks
|-
| ''Enterococcus'' spp, pen-susceptible
| Pen G 20-24 MU IV q24h continuous or 6 divided doses, or<br/>Ampicillin 12 g IV q24h continuous or in 6 divided doses
| Vanco 15-20 mg/kg IV q12h, or<br/>Dapto 6 mg/kg IV q24h, or<br/>Linezolid 600 mg PO/IV q12h
| May add aminoglycoside for 4-6 weeks if IE (shorter if merely bacteremia)
|-
| ''Enterococcus'' spp, pen-resistant
| Vanco 15-20 mg/kg IV q12h
| Dapto 6 mg/kg IV q24h, or<br/>Linezolid 600 mg PO/IV q12h
| May add aminoglycoside for 4-6 weeks if IE (shorter if merely bacteremia)
|-
| ''Pseudomonas aeruginosa''
| Cefepime 2 g IV q8-12h, or<br/>Mero 1 g IV q8h, or<br />Dori 500 mg IV q8h
| Cipro 750 mg PO q12h, or<br />Cipro 400 mg IV q8h, or<br />Aztreonam 2 g IV q8h, or<br />Ceftazidime 2 g IV q8h
| 6 weeks. Can consider double-coverage.
|-
| Enterobacteriaceae
| Cefipime 2 g IV q12h, or<br />Ertapenem 1 g IV q24h
| Cipro 500-750 mg PO q12h, or<br />Cipro 400 mg IV q12h
| 6 weeks
|-
| Beta-hemolytic streptococci
| Pen G 20-24 MU IV q24h continuous or 6 divided doses, or<br />Ceftriaxone 2 g IV q24h
| Vanco 15-20 mg/kg IV q12h
| 6 weeks
|-
| ''Proprionibacterium acnes''
| Pen G 20 MU IV q24h continuous or in 6 divided doses, or<br />Ceftriaxone 2 g IV q24h
| Clinda 600-900 mg IV q8h, or<br />Vanco 15-20 mg/kg IV q12h
| 6 weeks
|-
| ''Salmonella'' spp
| Cipro 500 mg PO q12h, or<br />Cipro 400 mg IV q12h
| Ceftriaxone 2 g IV q24h
| 6-8 weeks
|}

== Common Highly Bioavailable Oral Antibiotics ==

{|
! Oral agent
! Comments
|-
| Metronidazole 500 mg PO tid to qid
| Can be used in NVO from ''Bacteroides'' and other susceptible anaerobes.
|-
| Moxifloxacin 400 mg PO daily
| Not recommended as monomicrobial for staphylococci.
|-
| Linezolid 600 mg PO bid
| Can be used in initial course of ox-resistant staphylococci if other aren't available.
|-
| Levofloxacin 500-750 mg PO daily
| Not recommended as monomicrobial for staphylococci.
|-
| Ciprofloxacin 500-750 mg PO bid
| Not recommended as monomicrobial for staphylococci.
|-
| TMP-SMX 1-2 DS tabs PO bid
| Not recommended as monomicrobial for staphylococci. May need to monitor levels.
|-
| Clindamycin 300-450 mg PO qid
| Second-line for susceptible staphylococci.
|-
| Doxycycline and rifampin
| Mostly used for ''Brucella''
|}

== Treatment Failure ==

* Ongoing findings at the end of therapy do not necessarily signify failure
** This includes persistent pain, residual neurologic deficits, high ESR/CRP, and radiographic findings
* If the 4-week ESR/CRP is unchanged or increasing, that is suspicious for failure
* Repeat MRI, looking at paraspinal and epidural soft tissue changes, can be considered
* If suspicion is high enough, then repeat biopsy is indicated with histopathology

[[Category:Bone and joint infections]]
[[Category:IDSA guidelines]]