UniversitàdegliStudidiModenaeReggioEmiliaClinicadiMalattieInfettive

NEWGUIDELINESFORNATIVEVERTEBRALOSTEOMYELITIS

AndreaBedini

Modena8febbraio 2017

Clinical Infectious Diseases,2015;61(6):e26–46

RECOMMENDATIONS(IDSA2015)

• RECOMMENDATIONSFORCLINICALDIAGNOSTICS

• RECOMMENDATIONSFORCLINICALTHERAPY

• RECOMMENDATIONSFORCLINICALFOLLOW-UP

RECOMMENDATIONSFORCLINICALDIAGNOSTICS

When Should theDiagnosis ofNVOBeConsidered?

Neworworsening backorneck pain

One ofthefollowing:

• Fever

• ⬆ ESRo⬆ CRP(sens.:94-100%)

• BSIorendocarditis

• Recent S.aureus BSI

+

Fever +• Newneurologic symptoms

±

• Backpain

What Is theAppropriateDiagnostic EvaluationofPatientsWithSuspectedNVO?

• Neurologic examination

• Aerobes+anaerobes blood cultures (2sets),CRP,ESR

• SpineMRI (sensitivity of97%,specificity of93%,accuracy of94%).Alternatives (when MRIcannot beobtained):CTscan,Gallium Tc99bonescan,PET

• Bloodcultures andserology forBrucellaspp.(inendemic area)

• Fungal blood cultures (if epidemiologic risk orhost risk factors)

• PPDorQuantiferon TB(if risk forM.tuberculosis)

• EvaluationbyanIDspecialist andaspinesurgeon

When Should anImage-GuidedAspiration Biopsy orAdditionalWorkupBePerformed?

• Biopsy: when amicrobiologic diagnosis has not beenestablished

• NoBiopsy:- S.aureus,S.lugdunensis,orBrucella speciesbloodstream infection- Brucella serology:strongly positive

When abiopsy is performed,pathologic specimens should besent fromall patients tohelpconfirm adiagnosis

HowLongShouldAntimicrobial TherapyBeWithheldPriortoanImage-GuidedDiagnostic Aspiration Biopsy?

NEUROLOGICCOMPROMISE

Empiric antimicrobialtherapy

SEPSISor

Empiric antimicrobialtherapy

Immediate surgicalintervention

RECOMMENDATIONSFORCLINICALTHERAPY

When ShouldEmpiric Antimicrobial Therapy BeStarted?

Neurologic symptomsor

Instable hemodynamics

NO

NOTHERAPYuntil amicrobiologic

diagnosis

YES

STARTEMPIRICTHERAPYwithout amicrobiologic

diagnosis

THE CHOICE OF ANTIBIOTIC THERAPY

Blood coltures positive (S. aureus, S. lugdun., Brucella spp.)

orBrucella serology positive

orBiopsy positive

Start a pathogen-directedantibiotic therapy

Start a empiric antibiotic therapy:• Anti-staphylococcus• Anti-streptococcus• Anti- Gram negative bacilli

Blood coltures negative (S. aureus, S. lugdun., Brucella spp.)

+Brucella serology negative

+Biopsy negative

THE CHOICE OF ANTIBIOTIC THERAPY

Blood coltures positive (S. aureus, S. lugdun., Brucella spp.)

orBrucella serology positive

orBiopsy positive

Start a pathogen-directedantibiotic therapy

Start a empiric antibiotic therapy

Blood coltures negative (S. aureus, S. lugdun., Brucella spp.)

+Brucella serology negative

+Biopsy negative

Glycopeptide (vancomycin or teicoplanin) +

Quinolones (or Cephalosporins III)

What Is theOptimal Duration ofAntimicrobial Therapy?

DURATIONOFTHERAPY

Most ofNVO

6weeksoftreatment

Brucella spp.

3months oftreatment

(2 weeks IV, 4 weeks PO) (TB 12 months, Candida spp. 6-12 months)

Lancet2015;385:875–82

RCT, multicentres (71 centres in France)

Period: 2006-2011

• 176 patients: 6 weeks of treatment

• 175 patients: 12 weeks of treatment

Lancet2015;385:875–82

Lancet2015;385:875–82

Clinical Infectious Diseases 2016;62(10):1262–9

Observational cohort study5 centres in Korea: 2005-2012Population: 314 pts with HVO (2005-2012)

Clinical Infectious Diseases 2016;62(10):1262–9

Retrospective reviewObservational cohort study: 5 centres in KoreaPopulation: 314 pts with HVO (2005-2012)

- High risk of recurrence: >1 risk factor (MRSA, end stage renal disease, undrained abscesses)- Low risk of recurrence: 0 risk factor

All recurrence rates (microbiological andclinical)ofHVOinpatientsat low andhighrisk ofrecurrence according tothetotal duration of

antibiotic therapy

Microbiological recurrence rates ofHVOinpatients at low andhighrisk ofrecurrence according tothetotal duration ofantibiotic

therapy

Kaplan–Meierplotsshowing thecumulativeprobability ofrecurrence freesurvival after completing all antibiotic therapies

Patients at low risk ofrecurrence Patients at highrisk ofrecurrence

What Is theOptimal Duration ofAntimicrobial Therapy?

DURATIONOFTHERAPY

Low risk ofrecurrence

6-8weeksoftreatment

Highrisk ofrecurrence

> 8weeksoftreatment

End-stage renal disease

MRSA infection

Undrained abscesses*

YESNO

Device implantation**

*Clin Infect Dis 62: 1262, 2016 - ** Clin Infect Dis 60: 1330, 2015

What AretheIndicationsforaSurgical Intervention?

SURGICAL INDICATIONS:

• Progressiveneurologic deficits• Progressivedeformity• Spinal instability• Persistent orrecurrent BSI(without

alternative source)• Worsening pain

Despiteadequateantimicrobialtherapy

NO surgical debridement in patients who have worsening bonyimaging findings at 4–6 weeks in the setting of improvement in clinicalsymptoms, physical examination, and inflammatory markers

RECOMMENDATIONSFORCLINICALFOLLOW-UP

HowShould Failure ofTherapy BeDefined inTreatedPatientsWithNVO?

Thepresenceofone ofthefollowing donotnecessarily signify treatmentfailure:

• persistentpain

• residual neurologicdeficits

• elevatedmarkers ofsystemic inflammation

• radiographic findings

What Is theRole ofSystemic InflammatoryMarkers andMRIintheFollow-upofTreatedPatients WithNVO?

Monitorclinical

assesment

MonitorESR/CRP

after 4weeks

Noroutinelyfollow-upMRI

Only if poorclinical response If failure:

repeat biopsy

2 weeks 4 weeks 6 weeks 8weeks

STARTABTx

Thank you

THANK YOU!

Download the presentationfrom www.infettive.com