Hematogenous Vertebral Osteomyelitis Research Articles

Risk Factors and Outcomes of Hematogenous Vertebral Osteomyelitis in Patients With Staphylococcus aureus Bacteremia.

Hematogenous vertebral osteomyelitis (HVOM) is an incompletely understood complication of Staphylococcus aureus bacteremia (SAB). Eligible SAB patients with and without HVOM were prospectively enrolled from 1995 through 2019 at Duke University Health System. HVOM was diagnosed either radiographically or microbiologically. Multivariable logistic regression analysis was performed to identify clinical and microbial factors associated with HVOM risk. All bloodstream S. aureus isolates were genotyped using spa typing. Of 3165 cases of SAB, 127 (4.0%) developed HVOM. Patients who experienced HVOM were more likely to have community-acquired SAB (30.7% vs 16.7%, P < .001), have a longer time to diagnosis of SAB (median, 5 days; interquartile range [IQR], 2-10.5 vs median, 2 days; IQR, 0-4; P < .001), and to exhibit persistent bacteremia (48.8% vs 20.6%, P < .001). A significant number of HVOM patients developed infective endocarditis (26% vs 15.2%, P = .002). Overall, 26.2% (n = 33) of SAB patients with HVOM underwent surgical intervention. Methicillin resistance (46.6% vs 41.7%, P = .318) and bacterial genotype were not associated with the development of HVOM. At the 12-month follow-up, 22% of patients with HVOM had died. Of the surviving patients, 20.4% remained on antibiotic therapy, and 29.6% had recurrence of either HVOM or SAB. Among patients with SAB, HVOM risk was associated with clinical factors and not bacterial genotype. Despite being a rare complication of SAB, patients with HVOM had high all-cause mortality rates and healthcare resource requirements up to 1 year after their HVOM diagnosis. Close clinical monitoring is indicated in this vulnerable population.

Polysegmental and multilevel lesions in hematogenous vertebral osteomyelitis: assessment of immediate and long-term results

Objective. To analyze the results of treatment of disseminated (polysegmental and multilevel) forms of hematogenous vertebral osteomyelitis (HVO) as compared with those of monosegmental and monovertebral lesions.Material and Methods. A retrospective analysis of a monocenter cohort of 266 patients with hematogenous osteomyelitis of the spine for 2006 to 2019 was carried out. Patients were divided into two groups: Group A (polysegmental and multilevel lesions) included 33 (12.4 %) patients and Group B (monosegmental and monovertebral lesions) – 233 (87.6 %) patients. The main examination methods were: clinical, radiological (standardized roentgenography, CT), MRI, microbiological, histological and statistical ones.Results. Comparison revealed that involvement of the cervical (p &lt; 0.001) and thoracic (p = 0.014) spine was more typical for polysegmental and multilevel lesions. There was a tendency to the predominance of type A lesions according to the Pola classification in patients with local forms (p = 0.078) and to the increase in type C lesions in polysegmental and multilevel processes (p = 0.035). The number of neurological complications was higher in polysegmental and multilevel lesions (p = 0.003). There were no significant differences in the treatment results, the number of relapses and mortality rate between the compared groups.Conclusion. Lesions of the cervical and thoracic spine and the presence of a neurological deterioration are typical for multilevel and polysegmental HVO. The formation of a multilevel lesion in different regions of the spine with a gap of 2–4 weeks or more requires a separate implementation of the diagnostic algorithm, defining of classification criteria and differentiated treatment tactics for each focus.

196. Clinical characteristics of 98 patients presenting with hematogenous spinal osteomyelitis: An observational study

<h3>BACKGROUND CONTEXT</h3> Most spinal infection occurs in the wake of invasive procedures, wherein flora have been directly inoculated into the spine and its surrounding soft tissues. Hematogenous infections, on the other hand, result from bacterial spread from a distant site. Staphylococcus aureus is the most common cause of hematogenous spinal infections, and most cases resolve with a 6-week course of antibiotics. However, some patients, especially those that present with concurrent epidural abscess and neurological embarrassment, require debridement of the site and potential structural stabilization. Since very few studies report the clinical characteristics of patients requiring surgery or succumbing to this disease state, this study aims to detail our series of patients with hematogenous spinal osteomyelitis. <h3>PURPOSE</h3> To report clinical characteristics of patients with hematogenous spinal osteomyelitis <h3>STUDY DESIGN/SETTING</h3> Retrospective study. <h3>PATIENT SAMPLE</h3> A total of 98 patients with hematogenous vertebral osteomyelitis. <h3>OUTCOME MEASURES</h3> Preoperative (preop) and postoperative (postop) courses of antibiotics, surgery, reoperation, length of hospital stay, postop sequelae and death. <h3>METHODS</h3> The medical records of patients presenting to two tertiary care centers from January 2014 to January 2021 with hematogenous spinal osteomyelitis were abstracted using ICD-10 codes M46.20 to M46.59. We collected age, sex, body mass index (BMI), comorbidities, affected spinal region, microbiological details, type and duration of pre- and postop antibiotics, length of hospital stay (LOS), reoperation and mortality. Long-term antibiotics were those in use > 6 months. <h3>RESULTS</h3> A total of 98 consecutive patients presenting with hematogenous vertebral osteomyelitis were included. Demographically, the mean age was 62±10 years; 61.2% (n-=60) were male; mean BMI was 29.2±10.4. Most of the infections occurred in the lumbar region (44.2%), followed by the thoracic spine (37.9%), more than two spinal regions (9.5%) and cervical spine (8.4%). Biopsy was performed in 94.1% and returned positive cultures in 93.4%. Of the cultures taken, gram positive bacteria accounted for 69.2%, gram negative in 16.7%, and fungus in 2.6%. 11.5% of cultures returned no growth. 76 (77.6%) patients underwent surgery while 22 (22.4%) were treated with antibiotics only. Of the 76 undergoing surgery, 34.2% underwent secondary surgeries due to a heavy wound burden of necrotic tissue and pus or the failure of multimodal care including antibiotics and debridement. 51.6% of the patients had been prescribed antibiotics preoperatively, with a mean course of 37.2±25.7 days. Postoperative antibiotics were prescribed to all patients, with a mean length of 70.2 days. Mean LOS was 17.9±15.3 days. Additionally, 51.6% of the patients were prescribed long-term antibiotic therapy. The overall death rate was 3.1% (n=3). All 3 patients underwent surgery. Demographic and clinical characteristics of the deceased patients include a mean age of 64 years, majority male (66.7%), who had major comorbidities such as diabetes, anemia, obstructive lung disease and hypertension. Major cause of death was septic shock. Major post-infection sequelae occurred in 24.5% (n=24) of patients. Patients suffering sequelae had a mean age of 69.3 years, were mostly male (83%) and carried major comorbidities including diabetes, anemia, hypertension and renal disease. The most common sequelae were major motor weakness, wound dehiscence and meningitis. <h3>CONCLUSIONS</h3> This study describes the clinical characteristics of patients presenting with hematogenous spinal osteomyelitis, their treatment course and outcomes. As in other sites of infection, the presence of major comorbidities (diabetes, hypertension and renal failure) appear to increase the risk of developing post infection sequalae and death. Our population included patients hospitalized in a tertiary care center with spinal osteomyelitis. They were therefore more likely to carry concomitant diagnoses such as epidural abscess, resulting in a high rate of surgical intervention. A future study with a larger sample size utilizing logistic regression would be able to identify significant risk factors both for hematogenous infection itself and for failure of non-operative and initial operative care. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Периоперационные факторы риска осложнений и рецидивов при гематогенном остеомиелите позвоночника: анализ моноцентровой когорты

Study design Retrospective analysis of a single-center cohort of patients with pyogenic vertebral osteomyelitis. The purpose of the study was to review risk factors for perioperative complications and recurrences in patients diagnosed with hematogenous pyogenic vertebral osteomyelitis. Material and methods 141 inpatient records of hematogenous pyogenic vertebral osteomyelitis were reviewed at the Regional Clinical Hospital No. 2, Tyumen. Patients who developed complications, neurological deficits and recurrences were assigned to A group (n = 66), and those who did not included in B group (n = 75). Results Perioperative complications, recurrences, risk factors and neurological disorders that could develop with different treatment methods were explored. There was a greater risk of recurrences and a lower rate of neurological complications seen in chronic cases and drug addicts. There was a lower risk of intra- and postoperative complications seen in thoracic spine involvement, a greater risk of neurological deficit with involved cervical spine and a lower risk in the lumbar spine involvement. There was a lower risk of neurological disorders in type A and type B disorders, and a greater risk in type C disorders as categorized by E. Pola. There were no differences in recurrence rates among different types of involvement. HIV did not increase the risk of complications and relapses. Surgical site infection developed in 8.1 % cases of transpedicular fixation and in 6.9 % following ventral interventions. No correlation was observed between the recurrence and complication rate and the surgical methods used. Overall, recovery or stable remission was achieved in 88.6 % of cases after treatment of relapses. Conclusion Recurrences and complications were primarily caused by delayed diagnosis, co-morbidities and neurological deficits. No correlation was observed between the recurrence and complication rate and the surgical methods used. There was a greater risk of recurrences and a lower rate of neurological complications seen in chronic cases and drug addicts. Neurological disorders are common for cervical spine disorders. The risk of complications was dependent on the type of involvement as categorized by E. Pola. There was a lower risk of neurological disorders in type A and B disorders and a statistically greater risk in type C disorders.

Hospital mortality in hematogenous vertebral osteomyelitis

Objective. To analyze lethal outcomes in patients with hematogenous vertebral osteomyelitis.Material and Methods. Study design: retrospective analysis of medical records. A total of 209 medical records of inpatients who underwent treatment for hematogenous vertebral osteomyelitis in 2006–2017 were analyzed. Out of them 68 patients (32.5 %) were treated conservatively, and 141 (67.5 %) – surgically. The risk factors for lethal outcomes were studied for various methods of treatment, and a statistical analysis was performed.Results. Hospital mortality (n = 9) was 4.3 %. In patients who died in hospital, average time for diagnosis making was 4 times less (p = 0.092). The main factors affecting mortality were diabetes mellitus (p = 0.033), type C lesion according to the Pola classification (p = 0.014) and age over 70 years (p = 0.006). To assess the relationship between hospital mortality and the revealed differences between the groups, a regression analysis was performed, which showed that factors associated with mortality were Pola type C.4 lesions (OR 9.73; 95 % CI 1.75–54.20), diabetes mellitus (OR 5.86; 95 % CI 1.14–30.15) and age over 70 years (OR 12.58; 95 % CI 2.50–63.34). The combination of these factors increased the likelihood of hospital mortality (p = 0.001). Sensitivity (77.8 %) and specificity (84.2 %) were calculated using the ROC curve. In the group with mortality, the comorbidity index (CCI) was significantly higher (≥4) than in the group without mortality (p = 0.002). With a CCI of 4 or more, the probability of hospital death increases significantly (OR 10.23; 95 % CI 2.06–50.82), p = 0.005. Long-term mortality was 4.3 % (n = 9), in 77.8 % of cases the cause was acute cardiovascular pathology, and no recurrence of vertebral osteomyelitis was detected.Conclusion. Hospital mortality was 4.3 %, and there was no mortality among patients treated conservatively. The main risk factors were diabetes mellitus, type C lesion according to Pola and age over 70 years. There was a significant mutual burdening of these factors (p = 0.001). With CCI ≥4, the probability of death is higher (p = 0.005).

Routing and Treatment of Patients with Hematogenous Vertebral Osteomyelitis on the Tyumen Region Example

Background. Currently, various algorithms of tactical classifications and treatment regimens for hematogenous vertebral osteomyelitis (HVO) are proposed. However, all proposed approaches are designed for the treatment of patients in specialized multidisciplinary clinics departments, although the initial treatment often occurs in municipal polyclinics, private medical centers and district hospitals. The question is what the appropriate scope of diagnostic and therapeutic measures in institutions with different material and resource bases and how to ensure continuity according to the existing three-level system of medical care remains open. The aim of this studyis to determine the probable routing and treatment options for patients with HVO on the example of the Tyumen region, depending on the existing three-level system of providing medical care to the population.Object and Methods.The current Orders of the Ministry of Health of the Russian Federation and the Resolutions of the Government of the Tyumen Region were studied, on which basis a three-level system of providing medical care to the population was organized and organizations providing emergency and elective medical care to patients with HVO were identified. The volume of medical and diagnostic measures in patients with HVO in institutions of various levels, as well as their routing to the regional clinical hospital No. 2 in case of impossibility or inexpediency of providing specialized medical care at the place of primary treatment, is analyzed on the example of the Tyumen region. The clinical material is presented by 267 patients with HVO who were treated in the Tyumen regional clinical hospital No. 2 from 2006 to 2019, 78.7% of whom were treated in the profile of traumatology and orthopedics, 18.7% — neurosurgery and 2.6% — surgery. Results.The list of medical institutions that provide emergency and planned care in traumatology and orthopedics, neurosurgery in the Tyumen region is defined, depending on the level of the institution and the available material and resource base. A block diagram is proposed that determines the scope of medical and diagnostic measures in institutions of I-III levels and specialized departments of multidisciplinary clinical hospitals. The principle of determining the patient profile (surgical, orthopedic, neurosurgical) depending on the type and severity of the inflammatory lesion according to the classification E. Pola (2017) is proposed.Conclusion. The need for effective use of medical and diagnostic resources starting from level I is determined by clear routing of the patient to ensure the continuity of medical care. A full-fledged diagnosis is possible in institutions not lower than the third level with the mandatory determination of the lesion type and the severity of the inflammatory process. HVO treatment is advisable in level III institutions, specialized departments of regional clinical hospitals and federal institutions.

189. Risk Factors and Outcomes of Hematogenous Vertebral Osteomyelitis in Patients with staphylococcus Aureus Bacteremia: Results from a 20-year Prospective Cohort

BackgroundHematogenous vertebral osteomyelitis (HVOM) is a rare, but devastating complication of Staphylococcus aureus bacteremia (SAB). Risk factors and outcomes associated with HVOM among patients with SAB remain incompletely understood.MethodsAll adult, hospitalized, non-neutropenic patients with SAB were prospectively enrolled from 1995 to 2015. Additional data was subsequently collected on all patients with HVOM. Diagnosis of HVOM was made either radiographically or microbiologically by culture from the infection site. Patients who underwent lumbar puncture or spinal surgery within 30 days prior to the diagnosis of HVOM were excluded.ResultsOf 2,475 cases of prospectively enrolled patients with SAB, 90 (3.6%) developed HVOM. The most common site of involvement was the lumbar spine (65.6%). MRI was used in the diagnosis of 90% of patients and although only 28.9% underwent bone biopsy, 88.5% of these bone cultures grew S. aureus. Patients with HVOM were more likely to have community-acquired SAB (22.2% vs. 9.9%, P < 0.0001) and persistent bacteremia (47.8% vs. 20.5%, P < 0.0001). Patients with HVOM who required surgical intervention were more likely to have motor deficit (60.9% vs. 21.4%, P = 0.0013) and have associated epidural abscesses (69.6% vs. 44.8%, P = 0.0400). Prolonged antibiotic use for HVOM was common, with 13.3% remaining on therapeutic antibiotics and 16.6% on suppressive therapy at 6 months. This dropped to 2.2% on therapeutic and 15.5% on suppressive therapy at 12 months. All-cause mortality was high in the HVOM cohort at 14.4% at 90-days, increasing to a cumulative 18.9% and 20.0% at 6 and 12-months, respectively. Rates of readmission, recurrent bacteremia, paralysis, and mortality at 6 and 12-months were similar for those who required surgical intervention and those who did not.Demographics, comorbidities, and clinical characteristics of patients with and without hematogenous vertebral osteomyelitis (HVOM) ConclusionHVOM in patients with SAB was associated with high rates of all-cause mortality up to 12 months following date of diagnosis. Patients with community-acquired bacteremia and persistent bacteremia were more likely to develop HVOM.Disclosures Vance G. Fowler, Jr., MD, MHS, Achaogen (Consultant)Actavis (Grant/Research Support)Advanced Liquid Logics (Grant/Research Support)Affinergy (Consultant, Research Grant or Support)Affinium (Consultant)Allergan (Grant/Research Support)Ampliphi Biosciences (Consultant)Basilea (Consultant, Research Grant or Support)Bayer (Consultant)C3J (Consultant)Cerexa (Consultant, Research Grant or Support)Contrafect (Consultant, Research Grant or Support)Cubist (Grant/Research Support)Debiopharm (Consultant)Destiny (Consultant)Durata (Consultant)Forest (Grant/Research Support)Genentech (Consultant, Research Grant or Support)Integrated Biotherapeutics (Consultant)Janssen (Consultant, Research Grant or Support)Karius (Grant/Research Support)Locus (Grant/Research Support)Medical Biosurfaces (Grant/Research Support)Medicines Co. (Consultant)Medimmune (Consultant, Research Grant or Support)Merck (Consultant, Research Grant or Support)NIH (Grant/Research Support)Novadigm (Consultant)Novartis (Consultant, Research Grant or Support)Pfizer (Grant/Research Support)Regeneron (Consultant, Research Grant or Support)Tetraphase (Consultant)Theravance (Consultant, Research Grant or Support)Trius (Consultant)xBiotech (Consultant)

Transpedicular fixation for hematogenous pyogenic vertebral osteomyelitis

Objective. To analyze the effectiveness of conservative treatment and extrafocal transpedicular fixation in patients with uncomplicated hematogenous pyogenic vertebral osteomyelitis (PVO).Material and Methods. Ninetyseven medical records of in-patients who were treated for hematogenous PVO in 2007–2017 were analyzed. Among them, men accounted for 73.2 % (n = 71) and women – 26.8 % (n = 26). The acute and subacute forms of the disease were diagnosed in 62 (63.9 %) patients and chronic – in 35 (36.1 %). Type A according to Pola classification totaled 45 patients, type B – 49 and type C – 3. Sixtyfour (66.0 %) patients were treated conservatively, 33 (34.0 %) – using transpedicular fixation and 25 (75.8 %) – using minimally invasive technique. No fixators were placed in the affected vertebrae. All patients underwent antibacterial therapy lasting 6–12 weeks.Results. Good treatment results were obtained in 89 (91.8 %) patients. There were no differences in the severity of pain between the comparison groups before the start of treatment and after one year. However, the pain severity was significantly reduced (p = 0.001) over the time of treatment. Positive results of transpedicular fixation were obtained in 28 (84.8 %) cases, and after three repeated interventions – in 32 (94.1 %), and those of conservative treatment – in 61 (95.3 %) cases. The total number of relapses was 8 (8.2 %), of complications – 3 (3.1 %). The risk of relapse among operated drug addicts was significantly higher (p = 0.033). There were no deaths in the comparison groups, which is explained by the study inclusion and exclusion criteria. All discharged patients were followed-up on an outpatient basis for at least a year, and 72.2 % of them – from 1 year to 8 years.Conclusion. Transpedicular fixation is indicated for uncomplicated hematogenous pyogenic vertebral osteomyelitis, monosegmental lesions and in cases of demands on improved quality of life. The use of such a technique in drug addicts is not recommended.

Classifications of Non-Specific Hematogenous Vertebral Osteomyelitis. Critical Review and Suggestions for Clinical Use

For a long time classification of V.Ya. Fischenko published in 1983 and being solely descriptive was the main classification of vertebral osteomyelitis in the countries of the former ussr. In recent years some versions of tactical classifications appeared in the literature which were dedicated to standardization of tactics and methods of treatment. However, those classifications did not reflect distribution according to affection type, destruction degree, biomechanical instability and presence of neurological deficit and did not embrace all scenarios of disease progress.Purpose of the study — to compare existing classifications and to offer an adapted Russian language version of tactical classification for hematogenous vertebral osteomyelitis.Materials and Methods. The study included 209 patients with non-specific vertebral osteomyelitis treated in the period from 2006 till 2017. All cases of vertebral osteomyelitis were distributed in accordance with known classifications. The authors conducted the analysis of treatment tactics used in the clinic and by the authors of given classifications. The authors revealed a group of patients which is not classified in known literature.Results. Full match of treatment tactics with standardized approaches suggested by authors of new classifications was 61,5% (n = 126), partial match (applied treatment tactics does not contradict to suggested) — 20,0% (n = 41), which overall was 81,5% (n = 167). The authors refer to patients who underwent ventral sanation or reconstructive procedures. The majority of patients had the septic form of disease. Four out of 209 patients were not classified while three patients features isolated injury of vertebral processes and one patient — injury of CI-CII.Conclusion. Modern suggested classifications of hematogenous vertebral osteomyelitis are applicable in clinical practice and allow to standardize treatment algorithms. Tactics is determined not only by degree of destruction, involvement of paravertebral tissues, biomechanical instability of affected spine segment and neurological deficit, but by a presence of systemic inflammation response syndrome (SIRS). Considering the above it would be useful to introduce some additional subtypes which would characterize septic process of disease and determine the indications for sanation and reconstructive ventral procedures, which can be supplemented by instrumental fixation after stabilization of the patient.

Comment to the Article „Classifications of Non-Specific Hematogenous Vertebral Osteomyelitis. Critical Review and Suggestions for Clinical Use“

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Selection of an appropriate empiric antibiotic regimen in hematogenous vertebral osteomyelitis.

BackgroundEmpiric antibiotic therapy for suspected hematogenous vertebral osteomyelitis (HVO) should be initiated immediately in seriously ill patients and may be required in those with negative microbiological results. The aim of this study was to inform the appropriate selection of empiric antibiotic regimens for the treatment of suspected HVO by analyzing antimicrobial susceptibility of isolated bacteria from microbiologically proven HVO.MethodWe conducted a retrospective chart review of adult patients with microbiologically proven HVO in five tertiary-care hospitals over a 7-year period. The appropriateness of empiric antibiotic regimens was assessed based on the antibiotic susceptibility profiles of isolated bacteria.ResultsIn total, 358 cases of microbiologically proven HVO were identified. The main causative pathogens identified were methicillin-susceptible Staphylococcus aureus (33.5%), followed by methicillin-resistant S. aureus (MRSA) (24.9%), Enterobacteriaceae (19.3%), and Streptococcus species (11.7%). Extended spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and anaerobes accounted for only 1.7% and 1.4%, respectively, of the causative pathogens. Overall, 73.5% of isolated pathogens were susceptible to levofloxacin plus rifampicin, 71.2% to levofloxacin plus clindamycin, and 64.5% to amoxicillin-clavulanate plus ciprofloxacin. The susceptibility to these oral combinations was lower in cases of healthcare-associated HVO (52.6%, 49.6%, and 37.6%, respectively) than in cases of community-acquired HVO (85.8%, 84.0%, and 80.4%, respectively). Vancomycin combined with ciprofloxacin, ceftriaxone, ceftazidime, or cefepime was similarly appropriate (susceptibility rates of 93.0%, 94.1%, 95.8%, and 95.8%, respectively).ConclusionsBased on our susceptibility data, vancomycin combined with a broad-spectrum cephalosporin or fluoroquinolone may be appropriate for empiric treatment of HVO. Fluoroquinolone-based oral combinations may be not appropriate due to frequent resistance to these agents, especially in cases of healthcare-associated HVO.

Surgery is safe and effective when indicated in the acute phase of hematogenous pyogenic vertebral osteomyelitis

Background: The overall benefit of surgical management in the acute phase of hematogenous pyogenic vertebral osteomyelitis remains difficult to evaluate because of the balance between potential functional benefit versus complications of surgery.Methods: Between 2000 and 2013, in a tertiary care hospital, we analyzed a cohort of patients with hematogenous pyogenic vertebral osteomyelitis treated surgically and compared them to those treated medically. Neurologic deficit (using the ASIA impairment scale) and pain (using the analgesic level required) 4 months later, recurrences and infection-related deaths 12 months later were evaluated. A propensity score was developed to adjust for nonrandomized allocation to surgery.Results: Ninety patients were included (mean age 64 years, 63% male); 28 (31%) were treated surgically. After adjustment for the propensity score, the improvement in neurological deficit at 4 months did not differ between surgical and medical treatment (p = .82), but the reduction of pain tended to be greater in surgical versus medical treatment (p = .051). Recurrences of infection (5%) and infection-related deaths (12%) occurred at similar rates in both groups at 12 months (p = 1.00 for both).Conclusions: Patients with hematogenous pyogenic vertebral osteomyelitis requiring surgery improved equally as non-surgical patients in terms of neurological deficit and residual pain. This result was not hampered by increased complications related to surgery. When indicated, surgery is safe and effective in patients suffering from hematogenous pyogenic vertebral osteomyelitis.

Clinical Characteristics and Outcomes of Healthcare-Associated Hematogenous Vertebral Osteomyelitis

Background The incidence of hematogenous vertebral osteomyelitis (HVO) has increased over recent years, likely due to longer life expectancies, higher prevalence of chronic disease, and more effective diagnostic techniques. Recently, healthcare-associated infections, such as catheter-related and procedure-related bloodstream infections, also increase the risk of HVO. The aim of our study was to evaluate the clinical characteristics and outcomes of healthcare-associated HVO (HCA-HVO).Methods We conducted a retrospective chart review of adult patients with microbiologically diagnosed HVO from five tertiary-care hospitals over 8-year period. HCA-HVO was defined as onset of symptoms after 1 month of hospitalization or within 6 months after hospital discharge, or ambulatory manipulations in the 6 months before the diagnosis [Pigrau et al. Medicine (Baltimore) 2015; 94:e365]. We compared the clinical characteristics and outcomes of HCA-HVO with community-acquired HVO (CA-HVO) cases.ResultsIn total, 358 patients with microbiologically diagnosed HVO were included in final analysis. Of these 358 cases, 256 (63.1%) were CA-HVO and 132 (36.9%) were HCA-HVO according to the predefined criteria. The main causative pathogens identified were methicillin-susceptible Staphylococcus aureus (32%), followed by methicillin-resistant S. aureus (MRSA) (26%), aerobic gram-negative bacteria (24%), and Streptococcus species (11%). Compared with CA-HVO cases, patients with HCA-HVO had more neoplasm (13.6% vs. 5.8%, P = 0.01) and end-stage renal disease (8.3% vs. 2.2%, P = 0.007). MRSA was more frequent pathogens in HCA-HVO cases than in CA-HVO (37.1% vs. 17.7%, P = 0.01). Patients with HCA-HVO were more likely to be have the higher rates of persistent bacteremia for ≥7 days (24.2% vs. 15.5%, P = 0.04), 1-year mortality (18.2% vs. 11.5%, P = 0.08) and 1-year relapse (12.1% vs. 6.2%, P = 0.051).Conclusion In this study, more than one-third of HVO is health care associated. Patients with HCA-HVO were more likely to have underlying illness, and their causative pathogens were more frequently MRSA. Outcomes of HCA-HVO were poorer, which require prevention measures and early diagnosis.Disclosures All authors: No reported disclosures.

Vertebral Osteomyelitis: Unexpected Cause of Back Pain

Osteomyelitis is an inflammation of bone caused by a pyogenic organism. Osteomyelitis is one of the most important musculoskeletal infections, commonly occurring in long bones. Vertebral osteomyelitis is fairly rare and is often overlooked. It is usually acquired hematogenously, although there are other ways of infection. Only about half of patients develop fever > 38 °C and symptoms are unspecific. The most common organism is Staphylococcus aureus , with Pseudomonas aeruginosa being an unexpected pathogen accounting for about 6%. We present a case of a 56-year-old Hispanic male that visited emergency room presenting with back pain of 3 weeks of evolution being discharged home. Patient returned 2 days after with no improvement. Blood test returned under normal range. Physical exam showed a focal tenderness at thoracic level. Blood culture recovered Pseudomonas aeruginosa sensitive to levofloxacin. CT/MRI was performed and showed vertebral osteomyelitis. Antibiotic was started for 6 weeks. Therapy was guided with erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP). Patient was evaluated monthly for 6 months and improved. Vertebral osteomyelitis is a challenging diagnosis. The consequences of the disease are dire if not diagnosed on time. Historically, the diagnosis of vertebral osteomyelitis remains in a positive culture of bone biopsy. Nowadays, when handling a suspected hematogenous vertebral osteomyelitis, blood culture has gained importance. Whether a blood culture recovered a pathogen, therapy should be based on sensitivity and can be guided following ESR/CRP levels. This type of management can preclude invasive and expensive methods, such as bone biopsy. J Med Cases. 2017;8(8):246-248 doi: https://doi.org/10.14740/jmc2870w

Long-term prognosis of hematogenous vertebral osteomyelitis: Mortality, quality of life, and pain.

Hematogenous vertebral osteomyelitis (HVO) has a generally favorable prognosis if appropriate treatment is initiated in its early phase; however, some intractable cases with HVO can develop neurological impairment as well as spinal deformity during the course of treatment and these sequelae may lead to impaired quality of life (QOL). In this study, we aimed to evaluate the long-term relapse rate, mortality, and QOL of patients with HVO. In this retrospective case series study, medical records of 60 patients with HVO with a mean follow-up period of 8 years (5-23 years) were reviewed to assess demographic data, details of infection, and clinical course. Mortality rate was assessed using a Kaplan-Meier plot. QOL was measured using the EuroQol 5 Dimension (EQ-5D) questionnaire and residual pain using a numeric rating scale (NRS). HVO relapsed in 4 of 60 patients (7%). Overall 5-year survival rate in 60 patients with HVO was 85%. The factors associated with increased mortality were malignant tumor, diabetes mellitus, chronic use of glucocorticoids, and drug-resistant strains of staphylococcus. Female-to-male ratio, NRS, prevalence of neurological impairment were significantly higher in patients with low EQ-5D score (poor health) compared to those with high EQ-5D score (good health). Patients with HVO have shorter life expectancy if they have malignancy, diabetes mellitus, chronic use of glucocorticoids, and a history of drug-resistant strains of staphylococcus infection. Female gender, residual neurological defects and persistent back pain are associated with impaired QOL in patients with HVO.

Hematogenous vertebral osteomyelitis associated with intravascular device-associated infections – A retrospective cohort study

IntroductionAim of the study was to investigate the clinical, microbiological, radiological, and treatment characteristics of hematogenous vertebral osteomyelitis originating from infected intravascular devices. Patients and MethodsPatients with secondary hematogenous vertebral osteomyelitis caused by an infected intravascular device were included in this retrospective cohort study. Patients with prior spinal surgery were excluded. Categorical variables were compared using χ2 or Fisher's exact tests and continuous variables using the Mann–Whitney U test. ResultsSixty-seven patients with hematogenous vertebral osteomyelitis were included. Intravenous catheters were the source of infection in 45 patients (67%) and cardiovascular devices in 22 (33%). Fever was present in 21 patients (45%). The main pathogens were coagulase-negative staphylococci, isolated in 42 patients (63%), which grew from blood culture in 52 patients (87%), from vertebral tissue in 29 patients (56%) and from the explanted intravascular device in 18 patients (60%), where it was sampled. Infective endocarditis was diagnosed in 14 of 45 patients (31%), more common with cardiovascular devices than with intravascular catheters (56% versus 15%; P=0.008). ConclusionsIn patients with vertebral osteomyelitis, growth of coagulase-negative staphylococci in blood is highly suggestive for intravascular device-associated infection. Despite absence of systemic or local signs of inflammation at the site of the device, blood cultures should be collected and echocardiography performed in these patients.

Vertebral Osteomyelitis: Unexpected Cause of Back Pain

Osteomyelitis is an inflammation of bone caused by a pyogenic organism. Osteomyelitis is one of the most important musculoskeletal infections, commonly occurring in long bones. Vertebral osteomyelitis is fairly rare and is often overlooked. It is usually acquired hematogenously, although there are other ways of infection. Only about half of patients develop fever &amp;gt; 38 °C and symptoms are unspecific. The most common organism is &lt;i&gt;Staphylococcus aureus&lt;/i&gt;, with &lt;i&gt;Pseudomonas aeruginosa&lt;/i&gt; being an unexpected pathogen accounting for about 6%. We present a case of a 56-year-old Hispanic male that visited emergency room presenting with back pain of 3 weeks of evolution being discharged home. Patient returned 2 days after with no improvement. Blood test returned under normal range. Physical exam showed a focal tenderness at thoracic level. Blood culture recovered &lt;i&gt;Pseudomonas aeruginosa&lt;/i&gt; sensitive to levofloxacin. CT/MRI was performed and showed vertebral osteomyelitis. Antibiotic was started for 6 weeks. Therapy was guided with erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP). Patient was evaluated monthly for 6 months and improved. Vertebral osteomyelitis is a challenging diagnosis. The consequences of the disease are dire if not diagnosed on time. Historically, the diagnosis of vertebral osteomyelitis remains in a positive culture of bone biopsy. Nowadays, when handling a suspected hematogenous vertebral osteomyelitis, blood culture has gained importance. Whether a blood culture recovered a pathogen, therapy should be based on sensitivity and can be guided following ESR/CRP levels. This type of management can preclude invasive and expensive methods, such as bone biopsy. J Med Cases. 2017;8(8):246-248 doi: https://doi.org/10.14740/jmc2870w

Factors for Neurologic Sequelae in Patients With Hematogenous Vertebral Osteomyelitis

Factors for Neurologic Sequelae in Patients With Hematogenous Vertebral Osteomyelitis

Optimal Duration of Antibiotic Therapy in Patients With Hematogenous Vertebral Osteomyelitis at Low Risk and High Risk of Recurrence.

The optimal duration of antibiotic treatment for hematogenous vertebral osteomyelitis (HVO) should be based on the patient's risk of recurrence, but it is not well established. A retrospective review was conducted to evaluate the optimal duration of antibiotic treatment in patients with HVO at low and high risk of recurrence. Patients with at least 1 independent baseline risk factor for recurrence, determined by multivariable analysis, were considered as high risk and those with no risk factor as low risk. A total of 314 patients with microbiologically diagnosed HVO were evaluable for recurrence. In multivariable analysis, methicillin-resistant Staphylococcus aureus infection (adjusted odds ratio [aOR], 2.61; 95% confidence interval [CI], 1.16-5.87), undrained paravertebral/psoas abscesses (aOR, 4.09; 95% CI, 1.82-9.19), and end-stage renal disease (aOR, 6.58; 95% CI, 1.63-26.54) were independent baseline risk factors for recurrence. Therefore, 191 (60.8%) patients were classified as low risk and 123 (39.2%) as high risk. Among high-risk patients, there was a significant decreasing trend for recurrence according to total duration of antibiotic therapy: 34.8% (4-6 weeks [28-41 days]), 29.6% (6-8 weeks [42-55 days]), and 9.6% (≥8 weeks [≥56 days]) (P = .002). For low-risk patients, this association was still significant but the recurrence rates were much lower: 12.0% (4-6 weeks), 6.3% (6-8 weeks), and 2.2% (≥8 weeks) (P = .02). Antibiotic therapy of prolonged duration (≥8 weeks) should be given to patients with HVO at high risk of recurrence. For low-risk patients, a shorter duration (6-8 weeks) of pathogen-directed antibiotic therapy may be sufficient.

Therapeutic Outcomes of Hematogenous Vertebral Osteomyelitis With Instrumented Surgery

Patients with hematogenous vertebral osteomyelitis (HVO) occasionally require instrumentation for spinal stabilization. However, placing instrumentation in the setting of spinal infection raises concerns about recurrent infection due to bacteria adhering to the foreign material. In this study, we evaluated the therapeutic outcomes of patients with HVO who underwent instrumented surgery. We conducted a retrospective chart review of adult patients with microbiologically diagnosed HVO who underwent surgical intervention in 5 tertiary care hospitals over an 8-year period. A total of 153 patients with HVO underwent surgical management for their infections. Of these 153 patients, 94 (61.4%) underwent surgical debridement alone (noninstrumented surgery) and 59 (38.6%) underwent surgical debridement and instrumentation (instrumented surgery). The median durations of antibiotic therapy were 66 and 80 days for the noninstrumentation and instrumentation groups, respectively (P = .22). Clinical outcomes were similar between the groups, including rates of infection-related death (2.1% vs 0%; P = .52), primary failure (1.1% vs 5.1%; P = .30), and recurrence (4.8% vs 6.8%; P = .72). Among the instrumentation group, there was a significant decreasing trend for recurrence according to total duration of antibiotic therapy: 22.2% (4-6 weeks), 9.1% (6-8 weeks), and 2.6% (≥ 8 weeks; P = .04). Duration of pre-instrumentation antibiotic therapy and single-stage operation (vs 2-stage operation) were not risk factors for recurrence. Spinal instrumentation in patients with HVO may be safe with pathogen-directed prolonged antibiotic therapy and should not be abandoned or delayed solely because of the risk of recurrence.