Native Vertebral Osteomyelitis Research Articles

Plasma Microbial Cell-free DNA Next-generation Sequencing Can Be a Useful Diagnostic Tool in Patients With Osteoarticular Infections.

Recent advances in shotgun metagenomic sequencing (sMGS) for detecting microbial cell-free DNA (mcfDNA) in peripheral blood have shown promise across various patient populations. This study evaluates the application of sMGS for diagnosing osteoarticular infections (OAIs), a condition with significant diagnostic challenges. We conducted a retrospective analysis on 73 patients suspected of OAIs at the Mayo Clinic from 2019 to 2023, incorporating mcfDNA sMGS (Karius test [KT]) into their diagnostic evaluation. We categorized the clinical impact of KT on OAI diagnoses and management into 4 distinct outcomes. (1) KT was able to confirm an established diagnosis, (2) KT supported noninfectious diseases diagnosis, (3) KT established an unsuspected diagnosis, (4) KT did not add relevant information. In our cohort, KT was performed in 73 patients. Among the infected individuals, KT yielded positive results in 22 of 43 (51.2%) cases. Of these 22 cases, 11 (50%) showed agreement with conventional diagnostic workup, whereas in 5 (22.7%) cases, the KT established an unsuspected diagnosis. Native vertebral osteomyelitis diagnosis (P < .001) or OAIs with concomitant presence of endocarditis or endovascular infection (P = .005) were statistically associated with a definite, probable, or possible diagnostic certainty of KT result. In complex OAIs, KT enhanced diagnostic accuracy by 11.6%, proving especially beneficial in diagnosing native vertebral osteomyelitis and infections with concurrent endocarditis or endovascular complications. Our findings underscore the utility of KT in the diagnostic workflow for challenging OAI cases, potentially altering clinical management for a significant subset of patients.

The projected increase of vertebral osteomyelitis in Germany implies a demanding challenge for future healthcare management of aging populations.

Since an increase in the occurrence of native vertebral osteomyelitis (VO) is expected and reliable projections are missing, it is urgent to provide a reliable forecast model and make it a part of future health care considerations. Comprehensive nationwide data provided by the Federal Statistical Office of Germany were used to forecast total numbers and incidence rates (IR) of VO as a function of age and gender until 2040. Projections were done using autoregressive integrated moving average model on historical data from 2005 to 2019 in relation to official population projections from 2020 to 2040. The IR of VO is expected to increase from 12.4 in 2019 to 21.5 per 100,000 inhabitants [95% CI 20.9-22.1] in 2040. The highest increase is predicted in patients over 75years of age for both men and women leading to a steep increase in absolute numbers, which is fourfold higher compared to patients younger than 75years. While the IR per age group will not increase any further after 2035, the subsequent increase is due to a higher number of individuals aged 75years or older. Our data suggest that increasing IR of VO will seriously challenge healthcare systems, particularly due to demographic change and increasing proportions of populations turning 75years and older. With respect to globally fast aging populations, future health care policies need to address this burden by anticipating limitations in financial and human resources and developing high-level evidence-based guidelines for prevention and interdisciplinary treatment.

Identification of pathogen composition in a Chinese population with iatrogenic and native vertebral osteomyelitis by using mNGS

Background Early antimicrobial therapy is crucial regarding the prognosis of vertebral osteomyelitis, but early pathogen diagnosis remains challenging. Objective In this study, we aimed to differentiate the types of pathogens in iatrogenic vertebral osteomyelitis (IVO) and native vertebral osteomyelitis (NVO) to guide early antibiotic treatment. Methods A total of 145 patients, who had confirmed spinal infection and underwent metagenomic next-generation sequencing (mNGS) testing, were included, with 114 in the NVO group and 31 in the IVO group. Using mNGS, we detected and classified 53 pathogens in the 31 patients in the IVO group and 169 pathogens in the 114 patients in the NVO group. To further distinguish IVO from NVO, we employed machine learning algorithms to select serum biomarkers and developed a nomogram model. Results The results revealed that the proportion of the Actinobacteria phylum in the NVO group was approximately 28.40%, which was significantly higher than the 15.09% in the IVO group. Conversely, the proportion of the Firmicutes phylum (39.62%) in the IVO group was markedly increased compared to the 21.30% in the NVO group. Further genus-level classification demonstrated that Staphylococcus was the most common pathogen in the IVO group, whereas Mycobacterium was predominant in the NVO group. Through LASSO regression and random forest algorithms, we identified 5 serum biomarkers including percentage of basophils (BASO%), percentage of monocytes (Mono%), platelet volume (PCT), globulin (G), activated partial thromboplastin time (APTT) for distinguishing IVO from NVO. Based on these biomarkers, we established a nomogram model capable of accurately discriminating between the two conditions. Conclusion The results of this study hold promise in providing valuable guidance to clinical practitioners for the differential diagnosis and early antimicrobial treatment of vertebral osteomyelitis.

1287. Assessing the Utility of Vertebral Body / Disc Space Fluid Cell Differential in the Diagnosis of Native Vertebral Osteomyelitis

Abstract Background Current approaches to diagnosing suspected native vertebral osteomyelitis (NVO) rely on imaging and microbiological workup, including blood and CT-guided biopsy cultures. These existing diagnostic methods often result in ambiguity, necessitating additional tests to distinguish NVO from its mimics. Our study aims to validate pilot findings demonstrating that an elevated neutrophil differential (PMN) in vertebral bone biopsy/ disc space fluid aspirate is associated with NVO. This may allow stratification of patients with suspected NVO into those who can be monitored closely versus those who may benefit from further invasive testing or empiric antibiotic therapy (Fig 1). Figure 1: Proposed workup of patients with suspected native vertebral osteomyelitis guided by disc space/ vertebral body neutrophil (PMN) differential. Methods This analysis examines a subset of patients from a prospective cohort study, enrolling adults referred to Mayo Clinic's neuroradiology department for spine biopsy. After collecting routine clinical specimens, the needle is rinsed with saline into an EDTA tube for automated cell count and differential analysis. To evaluate the predictive capacity of neutrophil (PMN) differential for NVO, logistic regression models were employed, and receiver operating characteristic (ROC) curve analyses were conducted for various PMN percentage cutoff points. Results In this preliminary analysis, 39 patients were included, comprising 7 patients with NVO and 32 patients with alternative diagnoses. Baseline characteristics are presented in Table 1. All NVO patients received antibiotics within two weeks of the spine biopsy. The median biopsy sample PMN percentage for NVO patients was 83.0 (77.5-88.0), compared to 65.0 (56.5-69.5) for those without NVO (p=0.005) (Fig 2A). The estimated relationship between the probability of NVO and each measure across the full range of percentages is illustrated in Fig 2B. The optimal ROC curve point corresponds to a PMN differential of 72.5% (sensitivity=0.86, specificity=0.81) (Fig 3).Table 1:Baseline Characteristics of Patients Included in the Preliminary AnalysisFigure 2:A) Distribution of spine biopsy neutrophil percent by native vertebral osteomyelitis (NVO) status, B) Loess nonparametric smoother showing the relationship between the probability of NVO and biopsy sample neutrophil percentage.Figure 3:ROC curve analysis of neutrophil percent and NVO Conclusion This preliminary analysis indicates that an elevated PMN differential in spine biopsy samples may serve as a valuable diagnostic tool for NVO, with results seemingly unaffected by recent antibiotic intake. The PMN differential cutoff of 72.5% exhibited notable sensitivity and specificity. Investigations are ongoing to further validate these findings Disclosures Brett Freedman, MD, Clear Choice Therapeutics: Stocks/Bonds|Medtronic: Grant/Research Support|Neuroinnovations: Stocks/Bonds Aaron J. Tande, M.D., Musculoskeletal Infection Society: Board Member|Wolters Kluwer Health - Lippincott Williams &amp; Wilkins: Publishing royalties, financial or material support

1299. Clinical Characteristics of Native Vertebral Osteomyelitis in Patients with a History of Acupuncture

Abstract Background Considering that vertebral osteomyelitis (VO) can occur via various routes. It can be predicted that clinical characteristics may vary depending on the way of infection or risk factors of the disease. In this study, the clinical characteristics, causative pathogens, clinical features, and prognosis of the native VO in patients with a history of acupuncture were compared with those without a history of acupuncture. Methods This retrospective study was conducted at a university-affiliated hospital in Seoul, from May 2006 to February 2021. The patients of age 18 or older with native VO were enrolled. Data on demography, clinical presentation, treatment, causative organisms, and clinical outcomes were collected via electronic medical records. Results A total of 100 patients with VO were reviewed, among which 34 patients had a history of acupuncture before the diagnosis of VO. The frequency of Gram-positive cocci (GPC) was significantly higher in the acupuncture group than in the non-acupuncture group (p=0.016). Abscess was observed more frequently in the acupuncture group than in the non-acupuncture group (p=0.01). Patients with abscesses underwent surgical treatment more often than those without (p=0.021). There was no difference in clinical outcomes between the two groups, including mortality, neurologic sequelae, and recurrent after one year. Conclusion This study suggests that confirming a history of acupuncture may help predict the pathogen or clinical characteristics of the disease. If the patient has a history of acupuncture, GPC can be considered the causative organism. The presence of abscesses may lead to surgical treatment more frequently. Disclosures All Authors: No reported disclosures

Rifampin Based Therapy for Patients With Staphylococcus aureus Native Vertebral Osteomyelitis: A Systematic Review and Meta-analysis.

Native vertebral osteomyelitis (NVO) caused by Staphylococcus aureus is associated with high risk of treatment failure and increased morbidity. The role of rifampin-based therapy for the treatment of this condition is controversial. The goal of this systematic review and meta-analysis is to explore the efficacy and safety of rifampin-based therapy for the treatment of S. aureus NVO. We searched Cochrane, Embase, Medline, Scopus, and Web of Science databases for studies published up to May 2023, focusing on adults with NVO treated with or without rifampin-containing regimens. A random-effects model meta-analysis estimated relative risks and risk difference with 95% confidence intervals (CI). Thirteen studies (2 randomized controlled trials and 11 comparative cohort studies), comprising 244 patients with S. aureus NVO who received rifampin and 435 who did not, were analyzed. Meta-analysis showed that rifampin-based regimens were associated with lower risk of clinical failure (risk difference, -14%; 95% CI, -19% to -8%; P < .001; I2 = 0%; relative risk, 0.58; 95% CI, .37-.92, P = .02, I2 = 21%). Only 1 study reported on adverse events. All studies had a high or uncertain risk of bias, and the certainty of evidence was rated as very low. Adjunctive rifampin therapy might be associated with lower risk of S. aureus NVO treatment failure; however, the low certainty of evidence precludes drawing definitive conclusions that would alter clinical practice. A randomized trial is necessary to corroborate these findings.

Clinical characteristics of native vertebral osteomyelitis in patients with history of acupuncture

BackgroundConsidering that vertebral osteomyelitis (VO) can occur via various routes, it can be predicted that clinical characteristics may vary depending on the route of infection or risk factors of the disease. In this study, differences in clinical characteristics, causative pathogens, clinical features and prognosis were investigated in patients of native vertebral osteomyelitis with history of acupuncture. MethodsThis retrospective study was conducted at Kyung Hee University Hospital at Gangdong, Seoul. We extracted data of patients diagnosed with VO from May 2006 to February 2021 using an electronic database. Data on demography, clinical presentation, treatment, causative organisms and clinical outcomes were identified and compared according to the history of acupuncture. ResultsA total of 100 patients with VO were reviewed, among which 34 patients had a history of acupuncture prior to the diagnosis of VO. The frequency of Gram-positive cocci (GPC) was significantly higher in the acupuncture group than in the non-acupuncture group (p = 0.016). Abscess was observed more frequently in the acupuncture group than in the non-acupuncture group (p = 0.01). There was no difference in neurological sequelae and recurrence between the two groups. There was no difference in mortality between the two groups. (p = 0.098) ConclusionThis study suggests that confirming a history of acupuncture may help predict the pathogen or clinical characteristics of the disease. If the patient has a history of acupuncture, GPC can be considered as the causative organism, and the findings that abscesses and surgical treatment are more common may be helpful in evaluating patients.

Clinical features and outcome of vertebral osteomyelitis after spinal injection: is it worth the price?

PurposeSpinal injections are increasingly used for back pain treatment. Vertebral osteomyelitis (VO) after spinal injection (SIVO) is rare, but patient characteristics and outcome have not been well characterized. The aim of this study was to assess patient characteristics of SIVO in comparison to patients with native vertebral osteomyelitis (NVO) and to determine predictors for 1-year survival.MethodsThis is a single-center cohort study from a tertiary referral hospital. This is a retrospective analysis of Patients with VO who were prospectively enrolled into a spine registry from 2008 to 2019. Student’s t-test, Kruskal–Wallis test or Chi-square test were applied for group comparisons. Survival analysis was performed using a log-rank test and a multivariable Cox regression model.Results283 VO patients were enrolled in the study, of whom 44 (15.5%) had SIVO and 239 (84.5%) NVO. Patients with SIVO were significantly younger, had a lower Charlson comorbidity index and a shorter hospital stay compared to NVO. They also showed a higher rate of psoas abscesses and spinal empyema (38.6% [SIVO] vs. 20.9% [NVO]). Staphylococcus aureus (27%) and coagulase-negative staphylococci (CNS) (25%) were equally often detected in SIVO while S. aureus was more frequently than CNS in NVO (38.1% vs. 7.9%).Patients with SIVO (P = 0.04) had a higher 1-year survival rate (Fig. 1). After multivariate analysis, ASA score was associated with a lower 1-year survival in VO.ConclusionThe results from this study emphasize unique clinical features of SIVO, which warrant that SIVO should be estimated as a separate entity of VO.

975. Dalbavancin for the Treatment of Vertebral Osteomyelitis

Abstract Background Dalbavancin (DAL) provides an alternative to daily intravenous (IV) antibiotics for the treatment of infections when treatment in the outpatient setting is not practical. While clinical outcomes data for the treatment of osteomyelitis (OM) with dalbavancin has expanded, data specifically addressing vertebral OM remains limited. Methods We conducted a retrospective single center study to evaluate DAL use at our institution for patients with vertebral OM, including relevant treatment details and follow-up to 90 days post last DAL dose. All patients aged&amp;gt; 18 years who received at least one dose of DAL between 2015 and 2021 via medication records were included. Results Twenty-eight patients with vertebral OM (24 with native vertebral OM) were treated with DAL for at least a portion of a treatment course. The most commonly isolated organisms were methicillin-resistant Staphylococcus aureus (MRSA) (10; 35.7%) and methicillin-sensitive S. aureus (MSSA) (7; 25%). Cultures were negative for 7 patients (25%). Eight (28.5%) patients were bacteremic upon presentation, 5 (17.8%) with MRSA, 2 (7.1%) with MSSA, and 1 (3.6%) due to Enterococcus faecalis. All included patients had a history of substance use and 18 (64.2%) endorsed injection use. DAL was most commonly selected due to a history of injection drug use (19, 67.9%), lack of a safe home environment (6, 21.4%) or prior non-adherence to outpatient antibiotics (5, 17.9%). For the 11 patients who received one dose of 1500 mg, the mean duration of antibiotics prior to DAL was 29.3 days, 2 of these patients were intended for 2 dose regimens but did not complete a second dose. For the 17 patients who received 2 doses of 1500 mg, mean duration of antibiotics prior to DAL was 13.8 days. Adverse reactions were documented for 7 patients (25%), most commonly infusion reactions. Readmission for any reason at 30 days occurred for 1 patient (3.6%) and 2 patients (7.1%) at 90 days. Mortality at days 30 and 90 post-treatment were 0. Recurrence or relapse of infection at 30 and 90 days occurred for 1 (3.6%) patient each. Conclusion DAL appears to be safe and well-tolerated for the treatment of vertebral OM, although clinical data comparing it to standard of care regimens, especially for vertebral OM due to S. aureus is needed before it can be recommended as standard of care. Disclosures James S. Lewis, PharmD, FIDSA, Cidara: Advisor/Consultant|Merck: Advisor/Consultant|SeLux Diagnostics: Advisor/Consultant Monica K. Sikka, MD, F2G: Site research investigator.

Early switch to oral antibiotic therapy for the treatment of patients with bacterial native vertebral osteomyelitis: a quaternary center experience, systematic review, and meta-analysis.

Recent data suggest that oral therapy can be effective for bone infections. We aim to assess the efficacy of an early switch to oral therapy ( weeks) compared to a non-early switch in bacterial native vertebral osteomyelitis. We conducted a cohort study at Mayo Clinic, Rochester (MN), between 2019-2021 combined with a systematic review, which queried multiple databases. Data were analyzed using a random-effects model. The cohort study included 139 patients: two received an early switch. Of 3708 citations, 13 studies were included in the final analysis. Meta-analysis demonstrated no difference in treatment failure (odds ratio 1.073, 95 % confidence interval 0.370-3.116), but many studies presented high risk of bias. Current evidence is insufficient to conclude the proportion of patients with failure or relapse is different in the two groups. High-quality studies are warranted before early switch can be routinely recommended.

Factors Impacting the Yield of Image-Guided Biopsy in Native Vertebral Osteomyelitis: A 10-Year Retrospective Study.

Image-guided biopsies in patients with suspected native vertebral osteomyelitis (NVO) are recommended to establish the microbiological diagnosis and guide antibiotic therapy. Despite recent advances, the microbiological yield of this procedure remains between 48% and 52%. A better understanding of factors associated with this low yield may lead to improved microbiological diagnosis. We retrospectively identified patients with suspected NVO undergoing image-guided biopsies from January 2011 to June 2021 at our institution. Two hundred nine patients undergoing 248 percutaneous biopsies were included. Demographic data, biopsy and microbiologic techniques, clinical characteristics, and antibiotic use were collected. Multivariable logistic regression analysis was conducted to determine factors associated with microbiological yield. A total of 110 of 209 (52.6%) initial image-guided biopsies revealed positive microbiological results. This number increased to 121 of 209 (57.9%) when repeat image-guided biopsies were included. In multivariable analysis, aspiration of fluid was associated with a 3-fold increased odds of yielding a positive result (odds ratio [OR], 3.13; 95% confidence interval [CI], 1.39-7.04; P = .006), whereas prior antibiotic use was associated with a 3-fold decreased yield (OR, 0.32; 95% CI, .16-.65; P = .002). A univariate subgroup analysis revealed a significant association between the length of the antibiotic-free period and microbiological yield, with the lowest rates of pathogen detection at 0-3 days and higher rates as duration increased (P = .017). Prior antibiotic use in patients with suspected NVO was associated with a decrease in the microbiological yield of image-guided biopsies. An antibiotic-free period of at least 4 days is suggested to maximize yield. Successful fluid aspiration during the procedure also increases microbiological yield.

Utility of disc space aspirate cell counts and differentials in the diagnosis of native vertebral osteomyelitis.

Background: Aspiration of intervertebral disc space is often done to confirm the diagnosis of native vertebral osteomyelitis. A study has not been done examining the utility of cell counts and differentials of the aspirated fluid in diagnosing native vertebral osteomyelitis (NVO). Methods: In this feasibility study, we prospectively enrolled patients with a suspected diagnosis of NVO referred to the Division of Neuroradiology for image-guided needle aspiration of the intervertebral disc. In this study, manual cell count was done on the aspirated fluid, followed by a differential cytospin technique and touch prep. We obtained demographic, lab, and microbiologic data and used the receiver operating curve (ROC) for statistical analysis. Results: Over 12months, we performed 17 aspirates on 14 patients. The median age was 70.5years (range: 45-77). The median manual cell count on the aspirated fluid was 52cells (range: 0-6656), the median neutrophil percentage on the touch prep slide was 73 % (range: 5 %-100 %), and the median neutrophil percentage on the cytospin slide was 82 % (range: 0 %-100 %). Routine bacterial cultures were positive in five cases, and the 16S ribosomal RNA gene polymerase chain reaction was positive in two cases. The optimal cutoff for a cell count of 104 total nucleated cells offered a sensitivity and specificity of 86 %, and a neutrophil cutoff of 83 % was associated with a 71 % sensitivity and specificity. Conclusion: An image-guided aspirated specimen leukocyte differential of % neutrophils or a leukocyte count of was a sensitive and specific test for diagnosing patients with suspected NVO. Additionally, more extensive studies are warranted to confirm the findings.

Oral Versus Standard Antimicrobial Treatment for Pyogenic Native Vertebral Osteomyelitis: A Single-Center, Retrospective, Propensity Score-Balanced Analysis.

BackgroundInterest in shorter antimicrobial regimens and oral treatment for osteoarticular infections is growing. The aim of this study is to assess whether there is an association between the administration of an entirely oral antibiotic therapy (OT) and the clinical outcome of native vertebral osteomyelitis (NVOs).MethodsWe conducted a single-center, retrospective, observational study on consecutive patients with pyogenic NVOs over a 10-year period (2008–2018). We performed multivariate logistic regression analysis to identify risk factors for clinical failure, both in the whole population and in subgroups. The impact of OT versus standard treatment (intravenous induction followed by oral treatment whenever possible) was assessed in patients with a non-multidrug-resistant microorganism (MDRO) etiology, and the impact of a rifampin-containing regimen was assessed in patients affected by NVOs caused by staphylococci or of unknown etiology.ResultsThe study population included 249 patients, and 33 (13.3%) experienced clinical failure; the OT group consisted of 54 patients (21.7%). Multivariate regression analysis of the whole population selected Charlson comorbidity index (adjusted odds ratio [aOR], 1.291; 95% confidence interval [CI], 1.114–1.497; P = .001) and MDRO etiology (aOR, 3.301; 95% CI, 1.368–7.964; P = .008) as independent factors for clinical failure. Among patients affected by a non-MDRO NVO, OT was not associated with an increased risk of clinical failure (aOR, 0.487; 95% CI, .133–1.782; P = .271), even after adjustment for the propensity score of receiving OT. In the subgroup of patients with staphylococcal or unknown etiology, NVO rifampin was independently associated with favorable outcome (aOR, 0.315; 95% CI, .105–.949; P = .040).ConclusionsAn entirely oral, highly bioavailable treatment, including rifampin, may be as effective as parenteral treatment in selected patients with NVOs.

Correction of thrombocytopenia caused by linezolid with scheduled sequential tedizolid use in patients with vertebral osteomyelitis by antibiotic resistant Gram-positive organisms

IntroductionBecause of thrombocytopenia, linezolid treatment tends to be stopped before the completion of therapy for complicated infections that require prolonged antimicrobial administration. In contrast, tedizolid shows a favorable hematologic profile. The primary end-point of this study was to evaluate the efficacy of switching treatment to tedizolid in patients who developed thrombocytopenia during linezolid therapy. MethodsThis retrospective study was conducted in patients with vertebral osteomyelitis (VO) caused by antibiotic-resistant Gram-positive bacteria. Treatment failure was defined as the reappearance of infection signs within 2 weeks after stopping tedizolid and discontinuation of tedizolid because of continued thrombocytopenia or other adverse effects. ResultsEight patients with native VO (n = 3) and postoperative VO (n = 5) were included in the study. The causative organisms were MRSA in all patients except one. Platelet counts decreased from 35.2 ± 11.5 × 104/mm3 to 17.8 ± 6.2 × 104/mm3 during linezolid therapy and improved without washout period in all patients after switching to tedizolid on days 5–7 (28.6 ± 4.9 × 104/mm3, p = 0.002). Tedizolid therapy was completed and treatment failure was not observed in any patient. The duration of treatment was 20.0 ± 11.2 days for linezolid and 30.3 ± 9.5 days for tedizolid (total, 50.3 ± 10.7 days). One patient died because of underlying disease, and there was no recurrence in the remaining 7 patients (median follow-up 501 days). ConclusionsSwitching therapy to tedizolid improved thrombocytopenia that occurred during linezolid therapy, and it enabled the completion of therapy for VO patients.

A case report of native vertebral osteomyelitis caused by Cutibacterium modestum

BackgroundCutibacterium modestum was named in 2020. C. modestum was previously called Propionibacterium humerusii. Several implant-associated infections caused by Cutibacterium species have been previously reported, but native vertebral osteomyelitis due to these bacteria has rarely been reported.Case presentationA 72-year-old man, who had previously received several nerve block injections for low back pain, was referred to our hospital for deterioration in back pain in the last 1 month. MRI findings were suggestive of L5-S1 vertebral osteomyelitis. Blood cultures and bone biopsy culture revealed the presence of Gram-positive bacilli. The isolate was identified as C. modestum by 16SrRNA gene sequencing. A diagnosis of vertebral osteomyelitis caused by C. modestum was made. Minocycline followed by oral amoxicillin was administered for 3 months. His symptom improved and did not recur after treatment completion.ConclusionA case of vertebral osteomyelitis caused by C. modestum was encountered. Although C. modestum is very similar to C. acnes, it could be accurately identified by 16SrRNA gene sequencing. This case represents the first documented C. modestum infection in humans.

Culture Yield in the Diagnosis of Native Vertebral Osteomyelitis: A Single Tertiary Center Retrospective Case Series With Literature Review.

BackgroundVertebral osteomyelitis is a serious condition that requires prompt diagnosis to avoid delays in proper management. There is no well-defined gold standard for diagnosis. We describe the current diagnostic approach at our institution, with a focus on the yield of image-guided vertebral biopsy.MethodsWe performed a single-centre 10-year retrospective case series, including adults with imaging suggestive of vertebral osteomyelitis/discitis, with either positive blood cultures, and/or a vertebral biopsy. We defined positive histopathology as our gold standard for test characteristic evaluation of biopsy cultures.ResultsOut of 694 patients identified, 221 met our inclusion criteria, and 173/221 (78.2%) patients underwent a spinal biopsy. Of those patients with biopsies, 113 (65%) had received antibiotics within 2 weeks preceding their evaluation. Six of 43 (13.9%) bone specimens were positive by culture, while 66/152 (43.4%) of disc specimens were culture positive. Forty-seven of 84 (55.9%) histopathology (bone or disc) specimens were diagnostic for osteomyelitis/discitis. The sensitivity of bone and disk culture were 30.0% and 56.0%, respectively, with specificities of 92.8% and 75.0%, respectively. Twenty-three (13.4%) patients had repeat biopsies, including 10 bone specimens and 14 disc specimens, and 11 (47.8%) specimens had histopathology performed which diagnosed an additional 3/23 patients (13% additional diagnostic yield).ConclusionsCulture of percutaneous biopsy of disc resulted in the highest diagnostic yield. Histopathology added to the diagnostic yield in culture-negative specimens. Histopathologic evaluation of bone had better yield than bone culture. A repeat biopsy can add to the diagnostic yield.

Diagnosis of vertebral osteomyelitis.

Native vertebral osteomyelitis (NVO) is a potentially fatal infection which has seen a gradual increase in its incidence over the past decades. The infection is insidious, presenting with symptoms of back pain. Fever is present in about 60 % of patients. Prompt diagnosis of NVO is important to prevent the development of complications. Numerous laboratory and imaging tools can be deployed to accurately establish the diagnosis. Imaging techniques such as magnetic resonance, nuclear imaging, and computed tomography are essential in diagnosing NVO but can also be useful in image-guided biopsies. Laboratory tools include routine blood tests, inflammatory markers, and routine culture techniques of aspirated specimens. Recent advances in molecular techniques can assist in identifying offending pathogen(s). In this review, we detail the arsenal of techniques that can be utilized to reach a diagnosis of NVO.

A retrospective cohort study of bacterial native vertebral osteomyelitis and its management in the UK

• Causative organisms can be elusive, despite blood cultures and biopsy. • Those patients with greater comorbidities have higher rates of treatment failure. • Over half of patients experienced complications and 6% died within three months. • Empirical antimicrobials must target Staphylococcus aureus . • Diagnostic biopsy is recommended where blood cultures are non-diagnostic. Bacterial native vertebral osteomyelitis (NVO) can present diagnostic and therapeutic challenges leading to high levels of morbidity and mortality. To inform strategies aimed at improving outcomes in these patients, data are needed on the current aetiology, diagnostic interventions, management and risk factors for treatment failure. This was a retrospective, multicentre, observational cohort study of adult patients with bacterial NVO across the UK between 1st January 2015 and 31st December 2016. Infectious Disease Society of America (IDSA) guideline standards were selected and used to audit practice relating to the management of these patients. A total of 286 patients were included from 40 hospitals. An organism was identified in 61% of cases by blood culture or biopsy. Of these, 51% were due to Staphylococcus aureus and 12% were due to Gram-negative bacteria. When performed, biopsy obtained a microbiological diagnosis in 50% of cases. Nearly 10% of patients required admission to an Intensive Care Unit, 20% were re-admitted to hospital, 56% experienced complications and 6% died within 90 days. Higher Charlson comorbidity index (CCI) was significantly associated with treatment failure at one month ( p = 0.004). This study identified opportunities to improve UK practice in the investigation and management of bacterial NVO. The range of organisms isolated supports the use of diagnostic biopsy where blood cultures are non-diagnostic, to guide antimicrobial therapy and strive to avoid treatment failure or complications. This study shows a clear need for antibiotic guidelines to reflect the current aetiology of NVO and authors support the creation of a formal registry.

Native Vertebral Osteomyelitis in Patients with Staphylococcus Aureus Bacteremia

BackgroundThe purpose of the study was to assess the epidemiology, risk factors and outcomes of native vertebral osteomyelitis (NVO) in patients with Staphylococcus aureus bacteremia (SAB). MethodsA retrospective institutional review was conducted at Mayo Clinic, Minnesota. Patients aged ≥18 years with SAB who developed NVO from January 1, 2006 to December 31, 2020 were included and 3-month follow-up data were abstracted. Data pertaining to patient demographics, risk factors and outcomes were recorded using REDCap. A 1:2 nested case-control analysis was performed, and controls were matched according to age, sex and year of SAB diagnosis. ResultsA total of 103 patients had NVO. A majority (60.2%) of patients was male, with a median age of 62.0 years. Thirty-one (30.1%) cases were caused by methicillin-resistant S. aureus (MRSA). The lumbar spine was most commonly (57.6%) and the most commonly reported comorbid conditions included diabetes mellitus (36.9%) and coronary artery disease (27.2%). Mortality at three-month follow-up was 18.6%. Nested case-control analysis revealed that injection drug use (IDU) and tobacco consumption were significant risk factors associated with NVO, while chronic hemodialysis and chronic liver disease (CLD) were associated with a decreased risk of NVO. ConclusionsAtherosclerotic vascular disease was prominent in our contemporary cohort with NVO in the setting of SAB. Diabetes mellitus, tobacco consumption, older age and male sex likely contributed to this profile. Because IDU was associated with NVO, an increased number of cases should be anticipated among patients with IDU given the ongoing opioid epidemic in the United States.

Establishment of an interdisciplinary board for bone and joint infections

PurposeThe incidence of bone and joint infections is increasing while their treatment remains a challenge. Although guidelines and recommendations exist, evidence is often lacking and treatment complicated by complex clinical presentations and therapeutic options. Interdisciplinary boards shown to improve management of other diseases, seem potentially helpful. We describe the establishment of an osteomyelitis board to show the existing demand for such a platform.MethodsAll patients discussed in the board for bone and joint infections between October 2014 and September 2020 were included in this retrospective study. Data were extracted from patient records and analyzed descriptively.ResultsA total of 851 requests related to 563 patients were discussed in the board during the study period. After a run-in period of 3 years, a stable number of cases (> 170/year) were discussed, submitted by nearly all hospital departments (22 of 25). Recommendations were mainly related to antibiotic treatment (43%) and to diagnostics (24%). Periprosthetic joint infections were the most frequent entity (33%), followed by native vertebral osteomyelitis and other osteomyelitis. In 3% of requests, suspected infection could be excluded, in 7% further diagnostics were recommended to confirm or rule out infection.ConclusionsA multidisciplinary board for bone and joint infections was successfully established, potentially serving as a template for further boards. Recommendations were mainly related to antibiotic treatment and further diagnostics, highlighting the need for interdisciplinary discussion to individualize and optimize treatment plans based on guidelines. Further research in needed to evaluate impact on morbidity, mortality and costs.