The guidelines are published by the Infectious Disease Society of America. These guidelines include evidence and opinion-based recommendations for the diagnosis and management of patients with native vertebral osteomyelitis treated with antimicrobial therapy, with or without surgical intervention.
Native vertebral osteomyelitis in adults is often the result of hematogenous seeding of the adjacent disc space from a distant focus.
It is a rare spinal condition, native vertebral osteomyelitis is the most common form of hematogenous osteomyelitis for patients 50 to 70 years of age..
Native vertebral osteomyelitis (NVO) can be a difficult disease to diagnose as the symptoms are non-specific. These symptoms could be a back pain that does not relieve, fever, and elevated inflammation markers.
The new guidelines present a comprehensive framework for proper clinical diagnostics and treatment of the condition.
Here are the recommendations.
When to Suspect Native Vertebral Osteomyelitis
NVO should be suspected in patients with
- New or worsening back or neck pain and fever
- New or worsening back or neck pain + elevated ESR or CRP
- new or worsening back or neck pain and bloodstream infection or infective endocarditis (strong, low).
- Fever and new neurologic symptoms with or without back pain
- New neck or back pain, following a recent episode of Staphylococcus aureus bloodstream infection
Recommendations for Diagnostic Work Up
- Medical and motor/sensory neurologic examination
- Obtain bacterial (aerobic and anaerobic) blood cultures (2 sets) and baseline ESR and CRP
- Spine MRI
- If MRI is contraindicated (eg, implantable cardiac devices, cochlear implants, claustrophobia, or unavailability) or unavailable, consider one of the following
- Spine gallium/Tc99 bone scan
- Computed tomography scan
- Positron emission tomography when MRI cannot be obtained
- Special tests
- Consider blood cultures and serologic tests for Brucella species in patients from endemic areas for brucellosis
- Fungal blood cultures in patients at risk for fungal infection
- Tuberculin test purified protein derivative test or an interferon alpha release assay in patients at risk for Mycobacterium tuberculosis NVO (endemic areas, low immunity, HIV)
- When clinical, laboratory and imaging studies suggest NVO and microbiologic diagnosis has not been established by blood cultures or serologic tests.
- In patients with S. aureus, S. lugdunensis, or Brucella species bloodstream infection
- Not recommended in patients with suspected subacute NVO (high endemic setting) and strongly positive Brucella serology (strong, low).
- Addition of fungal, mycobacterial, or brucella cultures on image-guided biopsy and aspiration specimens should be done in patients with suspected NVO if epidemiologic, host risk factors, or characteristic radiologic clues are present (weak, low).
- Histopathology/cytology if sufficient sample is available
- Repeat Aspiration Biopsy/ percutaneous endoscopic discectomy and drainage/Excisional Biopsy
- Growth of skin concomitants from previous aspiration and the absence of concomitant bloodstream infection
- To exclude difficult-to-grow organisms (eg, anaerobes, fungi, Brucella species, or mycobacteria) in negative first image-guided aspiration biopsy
Treatment Recommendation for Non-Vertebral Osteomyelitis
If the patient is normal, stable hemodynamics and stable neurologic examination – wait for culture and sensitivity before starting antibiotic therapy.
Empirical antibiotic therapy should be started in cases of hemodynamic instability, sepsis, or severe or progressive neurologic symptoms. The antibiotics can be switched to specific antibiotics.
Antibiotics are recommended for a period of six weeks.
In case of Brucella species infection, antibiotics are given for 3 months.
Antibiotic agents that can be onsidered are given in the table
|Staphylococci, oxacillin susceptible|
|Staphylococci, oxacillin resistant||Vancomycin|
|Enterococcus species, penicillin susceptible|
|Enterococcus species, penicillin resistant||Vancomycin|
Indications for Surgery
- Progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate antimicrobial therapy.
- Surgical debridement with or without stabilization in patients with persistent or recurrent bloodstream infection if another source without alternative source has been ruled out
- Worsening pain despite appropriate medical therapy
It is advised to refrain from surgery in with worsening bony imaging findings at 4–6 weeks in the setting of improvement in clinical symptoms, physical examination, and inflammatory markers.
- Monitoring systemic inflammatory markers (ESR and or CRP) after approximately 4 weeks of antimicrobial therapy, in conjunction with a clinical assessment.
- A follow-up MRI to assess spinal tissues in patients with are judged to have a poor clinical response
Unchanged or increasing values of serum markers [ESR and CRP] after 4 weeks of treatment along with clinical assessment should bring suspicion of treatment failure.
- Obtain a follow-up MRI
- Obtain additional tissue samples for microbiologic either by aspiration biopsy or by open surgery.
- surgical sampling
Samples should be for histopathology, aerobic and anaerobic bacterial cultures, and fungal, brucella, and mycobacterial cultures. In select circumstances, serologic assays for uncommon causes should be considered as well.
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