Does surgery influence the outcome of Aspergillus osteomyelitis?

Abstract

We read with great interest the article by Gabrielli et al. [1]. The authors made a literature review of Aspergillus osteomyelitis and drew some conclusions about this kind of infection. However, we have some concerns about the influence of surgery on the outcome of Aspergillus osteomyelitis. In the article, Gabrielli et al. [1] drew the conclusion that ‘the combination of surgery and antifungal therapy did not significantly influence the outcome’, which cannot completely accord with the documents in the literature. In two recently published papers, Gamaletsou et al. [2] found that ‘there were fewer relapses in patients managed with surgery plus antifungal therapy in comparison to those managed with antifungal therapy alone (8% vs. 30%; p <0.006)’, and Koehler et al. [3] demonstrated higher survival rates in patients who received combined surgical and antifungal treatment than in those who received antifungal therapy only (78% versus 60%). Furthermore, about half of Aspergillus osteomyelitis was Aspergillus spondylitis, which may cause bone destruction, deformity and paraplegia and needs surgical intervention. Hence, the surgery performed in patients with Aspergillus osteomyelitis may include drainage, debridement, decompression and stabilization. We speculate that the ‘surgery’ used in the article by Gabrielli et al. [1] should be ‘drainage and debridement’, as recommended by the guidelines of the Infectious Diseases Society of America [2] in the treatment of Aspergillus osteomyelitis. It is well recognized that patients with neurological defects and extensive bony destruction require decompression and stabilization [1]. However, whether to perform drainage or debridement of the infected lesion in those patients who only show pain without significant instability or neural compression remains controversial, and high level evidence is absent. Gabrielli et al. [1] may provide appropriate clinical advice after excluding the patients who underwent decompression and stabilization.