First US Guideline for Vertebral Osteomyelitis Released

Laurie Barclay, MD

July 31, 2015

Persistent severe back pain may indicate vertebral osteomyelitis, a rare spine infection that must be diagnosed and treated correctly to prevent serious complications, according to a new Infectious Diseases Society of America (IDSA) guideline.

The guideline was published online July 30 in Clinical Infectious Diseases and on the IDSA website.

Because these complications may include paralysis and death, patients with severe back pain unresponsive to rest and analgesics should see an infectious disease physician, particularly if fever develops.

This infection, in which bacteria in the blood enter an intervertebral disc, can affect anyone but is more common in the elderly. Overall incidence is two to six per 100,000 annually. Staphylococcus aureus is the most common culprit.

"Back pain is so common — and usually not caused by infection — that diagnosis often is missed or delayed," lead author Elie F. Berbari, MD, from the Division of Infectious Disease at Mayo Clinic College of Medicine, Rochester, Minnesota, said in a news release. "The infection causes severe pain that often wakes the person at night and does not go away after pain management or rest. If that's the case, the doctor needs to start considering that something else is going on, especially if the patient has a fever."

Specific recommendations include the following:

  • Elevated diagnostic markers of inflammation, such as erythrocyte sedimentation rate and C-reactive protein, may suggest vertebral osteomyelitis.

  • Plain radiographs of the spine are not sensitive for early diagnosis.

  • Patients with elevated erythrocyte sedimentation rate and C-reactive protein should undergo magnetic resonance imaging to distinguish infection from disc herniation or other structural cause of back pain.

  • Unless patients are septic or have neurologic compromise, empiric antimicrobial therapy should be withheld until the microbiologic diagnosis is confirmed.

  • However, most patients with Staphylococcus aureus bloodstream infection within the preceding 3 months and compatible spine magnetic resonance imaging changes may be treated empirically without disc space aspiration.

  • Treatment usually includes intravenous antibiotics for 6 weeks, based on the results of culture and in vitro susceptibility testing.

  • Patients whose pain resolves after antibiotic treatment or surgery generally do not require repeat magnetic resonance imaging.

"It's important that the patient is seen by an expert familiar with the signs and symptoms of spine infections, who can differentiate between back pain due to mechanical reasons vs. infection," coauthor Steven K. Schmitt, MD, a member of the IDSA board of directors from the Cleveland Clinic in Ohio, said in the news release. "Early diagnosis and appropriate management can prevent disability, so a high index of suspicion and early ID consultation are central to a good outcome."

A panel of 11 experts, including infectious diseases physicians, an orthopedic surgeon, and a radiologist, wrote this first US evidence-based guideline dealing with vertebral osteomyelitis.

The IDSA provided support for these guidelines. Some of the guidelines authors reported various financial disclosures regarding with UpToDate, Pfizer, AstraZeneca, Gilead, Biologix, Pasteur Aventis, Astellas, Medpace, Cubist, and/or Ortho-McNeil.

Clin Infect Dis. Published online July 30, 2015. Full text


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