Vertebral osteomyelitis

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 species, 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 over 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