Native vertebral osteomyelitis (IDSA 2015) - Revision history

Aidan: stylized tables

2022-07-13T19:12:05Z

stylized tables

← Older revision		Revision as of 19:12, 13 July 2022
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	=== Common Parenteral Antibiotics ===		=== Common Parenteral Antibiotics ===

			{\| class="wikitable"
	{\|
	! Microorganism		! Microorganism
	! First-line		! First-line
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	=== Common Highly Bioavailable Oral Antibiotics ===		=== Common Highly Bioavailable Oral Antibiotics ===

			{\| class="wikitable"
	{\|
	! Oral agent		! Oral agent
	! Comments		! Comments

Aidan at 19:33, 15 August 2019

2019-08-15T19:33:57Z

← Older revision		Revision as of 19:33, 15 August 2019
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	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.		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 =		== Background ==

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

	= Diagnosis =		== Diagnosis ==

	== Clinical Clues ==		=== Clinical Clues ===

	* Suspect NVO in patients with new/worsening back/neck pain and any of the following:		* Suspect NVO in patients with new/worsening back/neck pain and any of the following:
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	* Suspect NVO in patients with new neurologic symptoms and fever, regardless of back pain		* Suspect NVO in patients with new neurologic symptoms and fever, regardless of back pain

	== Diagnostic Approach ==		=== Diagnostic Approach ===

	* Neurologic exam		* Neurologic exam
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	* Consider involving surgery		* Consider involving surgery

	== Biopsy ==		=== Biopsy ===

	* Biopsy not needed if blood cultures grow ''S. aureus'', ''Staphylococcus lugdenensis'', or ''Brucella'' or ''Brucella'' serology is strongly positive		* Biopsy not needed if blood cultures grow ''S. aureus'', ''Staphylococcus lugdenensis'', or ''Brucella'' or ''Brucella'' serology is strongly positive
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	** Can consider discectomy and drainage or open excisional biopsy		** Can consider discectomy and drainage or open excisional biopsy

	= Management =		== Management ==

	* If they are clinically stable with no neurologic compromise, then it is reasonable to withhold antimicrobials while attempting to establish a microbiological diagnosis		* If they are clinically stable with no neurologic compromise, then it is reasonable to withhold antimicrobials while attempting to establish a microbiological diagnosis
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	** No need for routine repeat imaging		** No need for routine repeat imaging

	== Common Parenteral Antibiotics ==		=== Common Parenteral Antibiotics ===

	{\|		{\|
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	\|}		\|}

	== Common Highly Bioavailable Oral Antibiotics ==		=== Common Highly Bioavailable Oral Antibiotics ===

	{\|		{\|
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	\|}		\|}

	== Treatment Failure ==		=== Treatment Failure ===

	* Ongoing findings at the end of therapy do not necessarily signify failure		* Ongoing findings at the end of therapy do not necessarily signify failure

Aidan at 01:15, 15 August 2019

2019-08-15T01:15:52Z

← Older revision		Revision as of 01:15, 15 August 2019
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		⚫	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.
	= Native vertebral osteomyelitis (IDSA 2015) =

		⚫	= Background =
⚫	~~<blockquote>~~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.
	</blockquote>
⚫	== Background ==

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

	== Diagnosis ==		= Diagnosis =

	=== Clinical Clues ===		== Clinical Clues ==

	* Suspect NVO in patients with new/worsening back/neck pain and any of the following:		* Suspect NVO in patients with new/worsening back/neck pain and any of the following:
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	* Suspect NVO in patients with new neurologic symptoms and fever, regardless of back pain		* Suspect NVO in patients with new neurologic symptoms and fever, regardless of back pain

	=== Diagnostic Approach ===		== Diagnostic Approach ==

	* Neurologic exam		* Neurologic exam
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	* Consider involving surgery		* Consider involving surgery

	==== Biopsy ====		== Biopsy ==

	* Biopsy not needed if blood cultures grow ''S. aureus'', ''Staphylococcus lugdenensis'', or ''Brucella'' or ''Brucella'' serology is strongly positive		* Biopsy not needed if blood cultures grow ''S. aureus'', ''Staphylococcus lugdenensis'', or ''Brucella'' or ''Brucella'' serology is strongly positive
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	** Can consider discectomy and drainage or open excisional biopsy		** Can consider discectomy and drainage or open excisional biopsy

	== Management ==		= Management =

	* If they are clinically stable with no neurologic compromise, then it is reasonable to withhold antimicrobials while attempting to establish a microbiological diagnosis		* If they are clinically stable with no neurologic compromise, then it is reasonable to withhold antimicrobials while attempting to establish a microbiological diagnosis
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	** No need for routine repeat imaging		** No need for routine repeat imaging

	=== Common Parenteral Antibiotics ===		== Common Parenteral Antibiotics ==

	{\|		{\|
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	\|}		\|}

	=== Common Highly Bioavailable Oral Antibiotics ===		== Common Highly Bioavailable Oral Antibiotics ==

	{\|		{\|
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	\|}		\|}

	=== Treatment Failure ===		== Treatment Failure ==

	* Ongoing findings at the end of therapy do not necessarily signify failure		* Ongoing findings at the end of therapy do not necessarily signify failure
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	* Repeat MRI, looking at paraspinal and epidural soft tissue changes, can be considered		* 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		* If suspicion is high enough, then repeat biopsy is indicated with histopathology

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

Aidan: Aidan moved page IDSA Native vertebral osteomyelitis 2015 to Native vertebral osteomyelitis (IDSA 2015) without leaving a redirect

2019-08-15T01:15:19Z

Aidan moved page IDSA Native vertebral osteomyelitis 2015 to Native vertebral osteomyelitis (IDSA 2015) without leaving a redirect

← Older revision		Revision as of 01:15, 15 August 2019
(No difference)

Maintenance script: Imported from text file

2019-08-11T18:05:53Z

Imported from text file

New page

= Native vertebral osteomyelitis (IDSA 2015) =

<blockquote>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.
</blockquote>
== 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 Cefazolin 1-2 IV q8h, or Ceftriaxone 2 g IV q24h
| Vanco 15-20 mg/kg IV q12h, or Dapto 6-8 mg/kg IV q24h, or Linezolid 600 mg PO/IV/iv q12h, or Levofloxacin 500-750 mg PO q24h and rifampin 600 PO mg daily, or 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 Linezolid 600 mg PO/IV q12h, or 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 Ampicillin 12 g IV q24h continuous or in 6 divided doses
| Vanco 15-20 mg/kg IV q12h, or Dapto 6 mg/kg IV q24h, or 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 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 Mero 1 g IV q8h, or Dori 500 mg IV q8h
| Cipro 750 mg PO q12h, or Cipro 400 mg IV q8h, or Aztreonam 2 g IV q8h, or Ceftazidime 2 g IV q8h
| 6 weeks. Can consider double-coverage.
|-
| Enterobacteriaceae
| Cefipime 2 g IV q12h, or Ertapenem 1 g IV q24h
| Cipro 500-750 mg PO q12h, or Cipro 400 mg IV q12h
| 6 weeks
|-
| Beta-hemolytic streptococci
| Pen G 20-24 MU IV q24h continuous or 6 divided doses, or 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 Ceftriaxone 2 g IV q24h
| Clinda 600-900 mg IV q8h, or Vanco 15-20 mg/kg IV q12h
| 6 weeks
|-
| ''Salmonella'' spp
| Cipro 500 mg PO q12h, or 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