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IDSA Osteomielite Vertebral Guideline 2015
IDSA Osteomielite Vertebral Guideline 2015
These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, ra-
diologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO).
They include evidence and opinion-based recommendations for the diagnosis and management of patients with
NVO treated with antimicrobial therapy, with or without surgical intervention.
Keywords. spondylodiscitis; osteomyelitis; Staphylococcus aureus; spine infection; discitis.
I. When Should the Diagnosis of NVO Be Considered? III. When Should an Image-Guided Aspiration Biopsy or
Recommendations Additional Workup Be Performed in Patients With NVO?
1. Clinicians should suspect the diagnosis of NVO in patients Recommendations
with new or worsening back or neck pain and fever (strong, 14. We recommend an image-guided aspiration biopsy in pa-
low). tients with suspected NVO (based on clinical, laboratory, and
2. Clinicians should suspect the diagnosis of NVO in patients imaging studies) when a microbiologic diagnosis for a known
with new or worsening back or neck pain and elevated ESR associated organism (S. aureus, Staphylococcus lugdunensis,
or CRP (strong, low). and Brucella species) has not been established by blood cul-
3. Clinicians should suspect the diagnosis of NVO in patients tures or serologic tests (strong, low).
with new or worsening back or neck pain and bloodstream 15. We advise against performing an image-guided aspiration bi-
infection or infective endocarditis (strong, low). opsy in patients with S. aureus, S. lugdunensis, or Brucella spe-
4. Clinicians may consider the diagnosis of NVO in patients cies bloodstream infection suspected of having NVO based on
who present with fever and new neurologic symptoms with clinical, laboratory, and imaging studies (strong, low).
or without back pain (weak, low). 16. We advise against performing an image-guided aspiration
5. Clinicians may consider the diagnosis of NVO in patients biopsy in patients with suspected subacute NVO (high en-
who present with new localized neck or back pain, following demic setting) and strongly positive Brucella serology
a recent episode of Staphylococcus aureus bloodstream infec- (strong, low).
tion (weak, low).
IV. How Long Should Antimicrobial Therapy Be Withheld Prior to
an Image-Guided Diagnostic Aspiration Biopsy in Patients With
II. What Is the Appropriate Diagnostic Evaluation of Patients With Suspected NVO?
Suspected NVO? Recommendations
Recommendations 17. In patients with neurologic compromise with or without
6. We recommend performing a pertinent medical and motor/ impending sepsis or hemodynamic instability, we recom-
sensory neurologic examination in patients with suspected mend immediate surgical intervention and initiation of em-
NVO (strong, low). piric antimicrobial therapy (strong, low).
2015 IDSA Guidelines for NVO in Adults • CID 2015:61 (15 September) • e27
V. When Is It Appropriate to Send Fungal, Mycobacterial, or risk factors, or characteristic radiologic clues are present
Brucellar Cultures or Other Specialized Testing Following an (weak, low).
Image-Guided Aspiration Biopsy in Patients With Suspected NVO? 19. We suggest the addition of fungal and mycobacterial cul-
Recommendations tures and bacterial nucleic acid amplification testing to ap-
18. We suggest the addition of fungal, mycobacterial, or bru- propriately stored specimens if aerobic and anaerobic
cellar cultures on image-guided biopsy and aspiration speci- bacterial cultures reveal no growth in patients with suspected
mens in patients with suspected NVO if epidemiologic, host NVO (weak, low).
2015 IDSA Guidelines for NVO in Adults • CID 2015:61 (15 September) • e29
2015 IDSA Guidelines for NVO in Adults • CID 2015:61 (15 September) • e31
2015 IDSA Guidelines for NVO in Adults • CID 2015:61 (15 September) • e33
2015 IDSA Guidelines for NVO in Adults • CID 2015:61 (15 September) • e35
2015 IDSA Guidelines for NVO in Adults • CID 2015:61 (15 September) • e37
Table 2. Parenteral Antimicrobial Treatment of Common Microorganisms Causing Native Vertebral Osteomyelitis
2015 IDSA Guidelines for NVO in Adults • CID 2015:61 (15 September) • e39
2015 IDSA Guidelines for NVO in Adults • CID 2015:61 (15 September) • e41
Evidence Summary One of the steps in developing a rational clinical research agen-
The most consistent finding in NVO treatment failure is persis- da in NVO is the identification of evidence-based gaps in infor-
tent or recurrent severe back pain [6]. However, many patients mation. The process of guideline development outlined above
with NVO otherwise thought to be cured report persistent pain serves as a natural means by which such gaps are identified.
at the time of last follow-up [6, 146, 147]. Patients with persistent Clinical questions identified by the NVO guideline authors
or progressive pain, systemic symptoms of infection, undrained could shape a research agenda for the diagnosis and manage-
or partially drained large epidural abscess, or persistently elevated ment of NVO. Questions are included below.
systemic inflammatory markers may be at highest risk for treat-
ment failure. Additional clinical findings associated with treat- Diagnostics
ment failure include diabetes mellitus, intravenous drug use, 1. What are the risk factors associated with the development
recurrent bloodstream infection, new-onset neurologic deficits, of NVO?
and sinus tract formation [6, 129, 142]. Rarely, patients may dem- 2. How to develop and validate diagnostic algorithms in pa-
onstrate persistent evidence of systemic infection despite antibi- tients with suspected NVO?
otic therapy, which may suggest failure of medical therapy and 3. What is the best strategy for patients with a nondiagnostic
the need for surgical intervention [7]. first aspiration biopsy?
There are limited data to guide the diagnostic approach to 4. What is the optimal timing for withholding antimic-
NVO patients with suspected treatment failure. Obtaining sys- robial therapy prior to image-guided diagnostic aspiration
temic inflammatory markers and a follow-up MRI may confirm biopsy?
the risk of treatment failure, clarify the presence of abscess in 5. What is the optimal size of the needle to be used in image-
need of drainage, and identify spinal instability that could benefit guided aspiration biopsy and the number of specimens to be
from surgical correction. Patients with evidence of progressive submitted in patients with suspected NVO?
epidural and/or paraspinal soft tissue infection on follow-up 6. What is the optimal timing and role of PEDD in patients
MRI appear to be at a greater risk for treatment failure [148]. with suspected NVO?
The frequency and utility of obtaining follow-up inflammatory 7. What is the role of [18F]-fluorodeoxyglucose PET scan-
laboratory markers (ESR, CRP) while patients are receiving anti- ning in diagnosis of patients with NVO?
microbial therapy for NVO have not been established. 8. Is there a role for of novel inflammatory cytokines in the
Therapeutic management of NVO patients with treatment diagnosis of NVO and follow-up of patients with NVO (ie, pro-
failure should be tailored to the suspected reason for failure. calcitonin, IL-6)?
Consultation with a surgeon and infectious disease physician 9. What is the optimal role for the use of molecular diagnos-
experienced in the treatment of spinal infections may be war- tic techniques in the diagnosis of NVO?
ranted in patients with suspected or proven treatment failure.
NVO patients with established treatment failure have been Management
treated successfully with medical therapy alone or combined 1. What are the optimal and most cost-effective algorithms
medical/surgical therapy. The decision of whether surgical in- of surgical and medical treatment strategies for the manage-
tervention is warranted needs to be individualized, and incorpo- ment of patients with NVO?
rates similar principles as to whether to perform surgery at the 2. What is the optimal duration of parenteral therapy?
time of NVO diagnosis or not. 3. What are the role, timing, and duration of oral antimicro-
In NVO patients with suspected treatment failure in whom bial therapy as an alternative or following a course of parenteral
surgical debridement is not planned, one should consider therapy?
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