Vertebral osteomyelitis: Difference between revisions
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*[[Staphylococcus aureus]] |
*[[Staphylococcus aureus]] |
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*Other [[Gram-positive cocci]], including [[viridans group streptococci]], [[Streptococcus bovis]], [[enterococci]], [[Streptococcus agalactiae]], group C and G [[streptococci]] |
*Other [[Gram-positive cocci]], including [[viridans group streptococci]], [[Streptococcus bovis]], [[enterococci]], [[Streptococcus agalactiae]], group C and G [[streptococci]] |
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*Less commonly, [[coagulase-negative staphylococci]], [[Gram-negative bacilli]], including [[Pseudomonas aeruginosa]], and [[Candida |
*Less commonly, [[coagulase-negative staphylococci]], [[Gram-negative bacilli]], including [[Pseudomonas aeruginosa]], and [[Candida]], especially in patients with indwelling lines or injection drug use |
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*[[Tuberculosis]] |
*[[Tuberculosis]] |
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*[[Brucella melitensis|Brucella]], in patients from endemic countries, can be as high as 25% of cases |
*[[Brucella melitensis|Brucella]], in patients from endemic countries, can be as high as 25% of cases |
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==Management== |
==Management== |
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*IV or highly bioavailable oral (metronidazole, fluoroquinolones, linezolid, TMP-SMX, clindamycin, and doxycycline/rifampin) |
*IV or highly bioavailable oral ([[metronidazole]], [[fluoroquinolones]], [[linezolid]], [[TMP-SMX]], [[clindamycin]], and [[doxycycline]]/[[rifampin]]) |
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**Can double-cover ''Enterococcus'' with an aminoglycoside for 4 to 6 weeks |
**Can double-cover ''[[Enterococcus]]'' with an [[Aminoglycosides|aminoglycoside]] for 4 to 6 weeks |
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*Duration: 6 weeks for most, but 3 months for ''Brucella'' |
*Duration: 6 weeks for most, but 3 months for ''[[Brucella]]'' |
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* |
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===''Brucella''=== |
===''Brucella''=== |
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*Combination of [[doxycycline]] and [[rifampin]] |
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*Doxycycline/rifampin |
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*Duration: 3 months |
*Duration: 3 months |
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* Often treated with retention of hardware, especially in early-onset disease[[CiteRef::atesok2020fa]] |
* Often treated with retention of hardware, especially in early-onset disease[[CiteRef::atesok2020fa]] |
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* Early onset (<4 to 6 weeks post-op) |
* Early onset (<4 to 6 weeks post-op) |
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** I&D with retention of hardware and bone graft material, with primary closure |
** I&D with retention of hardware and bone graft material, with primary closure instead of a drain, if feasible |
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* Late onset (more than 4 to 6 weeks post-op) |
* Late onset (more than 4 to 6 weeks post-op) |
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** Fusion achieved: incision and drainage with removal of hardware |
** Fusion achieved: incision and drainage with removal of hardware |
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Latest revision as of 23:17, 12 March 2022
Background
Microbiology
- Staphylococcus aureus
- Other Gram-positive cocci, including viridans group streptococci, Streptococcus bovis, enterococci, Streptococcus agalactiae, group C and G streptococci
- Less commonly, coagulase-negative staphylococci, Gram-negative bacilli, including Pseudomonas aeruginosa, and Candida, especially in patients with indwelling lines or injection drug use
- Tuberculosis
- Brucella, in patients from endemic countries, can be as high as 25% of cases
Management
- IV or highly bioavailable oral (metronidazole, fluoroquinolones, linezolid, TMP-SMX, clindamycin, and doxycycline/rifampin)
- Can double-cover Enterococcus with an aminoglycoside for 4 to 6 weeks
- Duration: 6 weeks for most, but 3 months for Brucella
Brucella
- Combination of doxycycline and rifampin
- Duration: 3 months
With Orthopedic Hardware
- Often treated with retention of hardware, especially in early-onset disease1
- Early onset (<4 to 6 weeks post-op)
- I&D with retention of hardware and bone graft material, with primary closure instead of a drain, if feasible
- Late onset (more than 4 to 6 weeks post-op)
- Fusion achieved: incision and drainage with removal of hardware
- Fusion not achieved: retention of hardware with suppressive antibiotics until fusion is achieved, then removal of hardware
Prognosis
- Cure rates are 70-90% with 6 weeks of antibiotics, and are not higher with longer durations (per a single RCT)
- Poor prognosis is associated with multidisc disease, the presence of concomitant epidural abscess, lack of surgical therapy, infection with S. aureus, old age, or the presence of significant comorbidities
References
- ^ Kivanc Atesok, Alexander Vaccaro, Martina Stippler, Brendan M. Striano, Michael Carr, Michael Heffernan, Steven Theiss, Efstathios Papavassiliou. Fate of Hardware in Spinal Infections. Surgical Infections. 2020;21(5):404-410. doi:10.1089/sur.2019.206.
