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Prolonged antibiotic therapy is often recommended for the treatment of spinal infections. This study aimed to evaluate the efficacy and safety of outpatient intravenous (IV) antibiotic therapy for spinal neurosurgery patients with spondylodiscitis. We carried out a retrospective study involving 67 patients who were administered peripherally inserted central catheter (PICC) for IV antibiotic treatment from January 2020 to December 2022. We assessed patient data concerning infections and neurosurgical concerns. Each patient underwent a minimum of 6 weeks of IV antibiotics, both as inpatients and outpatients. The study included 67 patients with a median age of 61 years (SD +/- 14.18 years), with approximately 44% being female. The average hospital stay for inpatient treatment was 20 days (SD +/- 8.8 days). Subsequent outpatient antibiotic therapy lasted an average of 70.32 days (SD +/- 18.24 days), with outpatient IV therapy accounting for 44.74 days (SD +/- 9.15 days). The most common pathogens identified were Staphylococcus epidermidis and methicillin-sensitive Staphylococcus aureus. Microbiological analysis did not detect any pathogens in 18% of patients. Radiographic and laboratory evidence of spondylodiscitis was absent in 99% of patients during the final follow-up. No catheter-related complications occurred. Outpatient IV antibiotic therapy using a PICC line catheter is a safe and effective treatment option for spinal infections, especially in elderly patients., Competing Interests: Declarations. Ethical approval: The study protocol was approved by the ethics committee of the Ludwig-Maximilian-University Munich (Bavaria, Germany) on May 26th, 2023, reference number 2023 − 0304. Consent to participate: All patients provided informed consent for participation in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Pyogenic spondylodiscitis is an uncommon but important clinical condition that often requires medical and/or surgical management. We report a case of spondylodiscitis caused by a rare pathogen, Gemella morbillorum. To date, worldwide, only six such cases of confirmed spondylodiscitis infection with this rare pathogen have been documented, and this is the first reported case in South Africa. The patient was a 55-year-old female who presented to us with a 1-month history of severe back pain radiating to her left leg. She reported to us that she visited the dentist around the time of onset of the symptoms. A workup showed raised inflammatory markers, and a positron emission tomography scan indicated features of discitis at level L2/L3. Tissue cultures from a biopsy identified G. morbillorum species infection, and she was treated successfully with antibiotics for 6 weeks. It is important to have a high index of suspicion when a patient has a history of dental work, and to rule out associated infection such as endocarditis. Treatment with culture-driven antibiotics yields good results.

Pyogenic spondylodiscitis is an uncommon but important clinical condition that often requires medical and/or surgical management. We report a case of spondylodiscitis caused by a rare pathogen, Gemella morbillorum. To date, worldwide, only six such cases of confirmed spondylodiscitis infection with this rare pathogen have been documented, and this is the first reported case in South Africa. The patient was a 55-year-old female who presented to us with a 1-month history of severe back pain radiating to her left leg. She reported to us that she visited the dentist around the time of onset of the symptoms. A workup showed raised inflammatory markers, and a positron emission tomography scan indicated features of discitis at level L2/L3. Tissue cultures from a biopsy identified G. morbillorum species infection, and she was treated successfully with antibiotics for 6 weeks. It is important to have a high index of suspicion when a patient has a history of dental work, and to rule out associated infection such as endocarditis. Treatment with culture-driven antibiotics yields good results.

Objective: To describe for intervertebral spondylodiscitis (IS) its clinical characteristics, treatment approaches with intravenous (IV) antibiotics, and clinical implications of changes in treatment approach., Study Design: This retrospective study included all children aged 0-18 years diagnosed with imaging-confirmed thoracic and lumbar IS from 2000 to 2022 at a tertiary pediatric hospital. Patients with longer IV treatment regimen were compared with those with a shorter clinically directed IV to oral regimen., Results: In all, 124 cases were included with median age 14.9 months (IQR, 12.7-19.4 months) at diagnosis. Irritability and pain while changing diapers were common symptoms (52.4% and 49.2%, respectively). Elevated erythrocyte sedimentation rate (ESR) was the most common laboratory finding (95%; median, 50 mm/h [IQR 34-64 mm/h]). Elevated erythrocyte sedimentation rate was found in higher proportions (95%) compared with elevated C-reactive protein (76%; median, 1.8 mg/dL; P < .001). Since implementing the shorter clinically directed IV treatment duration for patients with thoracic and lumbar IS, hospitalization duration was decreased from a median of 12 to 8 days (P = .008) and IV treatment duration by a median of 14 to 8 days (P < .001). Only 1 patient (1.6%) in the clinically directed treatment group required rehospitalization owing to failure of therapy. Conversely, 9 of 124 children in the cohort suffered from IV treatment-related complications; all had been treated IV for prolonged periods., Conclusions: Early transition to oral treatment in pediatric spondylodiscitis seems to be appropriate clinically and shortens hospital stay and IV treatment duration without major negative clinical impact., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Hereditary haemorrhagic telangiectasia (HHT) leads to arteriovenous malformations (AVM) that increase the risk of haemorrhage and cause right-left shunting bypassing the reticuloendothelial system increasing the risk for recurrent infections. A 60+ year old male patient with HHT type 1 (status post six pulmonary AVM coiled embolisations) with epistaxis presented with intractable back pain, methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia and spinal MRI revealing spondylodiskitis and L4-L5 epidural phlegmon. He has an extensive history of deep-seated infections including two prior spinal infections, two joint infections and one muscular abscess-all with MSSA. The patient was treated with 6 weeks of intravenous nafcillin with symptom resolution. Infectious disease prescribed cefalexin 500 mg daily for suppression of infection recurrence considering his extensive deep-seated infection history and multiple risk factors. This case raises important questions about preventative antimicrobial management of high-risk patients with HHT, which is a grey area in current international HHT guidelines., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: The authors have no funding or conflicts of interest to disclose.

Introduction: Metronidazole-induced encephalopathy is an uncommon but potentially severe complication of metronidazole treatment. Although the exact pathophysiology remains elusive, proposed hypotheses include RNA binding, neurotoxicity from free radicals, and modulation of neurotransmitter receptors. Most cases demonstrate improvement upon discontinuation of metronidazole, highlighting the importance of early recognition. Magnetic resonance imaging plays a critical role in diagnosing metronidazole-induced encephalopathy, with characteristic imaging findings frequently observed in the dentate nuclei and corpus callosum., Case Summary: A 63-year-old man treated with metronidazole for lumbar spondylodiscitis developed neurological symptoms consistent with metronidazole-induced encephalopathy., Images: Magnetic resonance imaging revealed characteristic bilateral hyperintense lesions in the cerebellar dentate nuclei, corpus callosum, and brainstem. Prompt recognition and discontinuation of metronidazole led to symptom resolution., Conclusion: This case underscores the importance of clinicians and radiologists being aware of this condition and emphasizes the pivotal role of magnetic resonance imagining in establishing the diagnosis.

Objective: The primary goal of this study was to establish the current microbial trends in vertebral osteomyelitis/discitis (VOD) amid the opioid epidemic and to determine if intravenous drug use (IVDU) predisposes one to a unique microbial profile of infection., Methods: The authors performed a retrospective cohort study consisting of 1175 adult patients diagnosed with VOD between 2011 and 2022 at a single quaternary center. Data were acquired through retrospective chart review, with pertinent demographic and clinical information collected., Results: Staphylococcus aureus was the most cultured organism in both the IVDU and non-IVDU groups at 56.1% and 40.7%, respectively. In the IVDU cohort, Serratia marcescens was the next most prevalently cultured organism at 13.9%., Conclusions: The present study demonstrates that in the IVDU population S. marcescens is an organism of high concern. The potential for Serratia spp. infection should be accounted for when selecting empirical antimicrobial therapy in VOD patients.

Nocturnal crying in toddlers has a broad spectrum of causes, including psychosocial and somatic causes, whereby the majority are self-limiting and do not need referral to specialist medical care. Although uncommon, atypical presentations of nocturnal crying-such as spondylodiscitis-require referral to specialist medical care, especially when combined with discomfort. In this case report, we present a case of a 15-month-old girl with an atypical presentation of nocturnal crying in combination with back pain., Competing Interests: Conflicts of interest None to report. The authors would like to thank the patients’ parents for providing their consent for this case report. The authors would also like to thank M. Reijnierse, A.J. van der Molen, V. Fejzovic, B. Boekestijn, D.A.W. Eijspaart, Y. Tank, J.L. Bloem (Department of Radiology, Leiden University Medical Centre) and L.F. de Geus-Oei (Department of Nuclear Medicine, Leiden University Medical Centre) for their radiological assessments., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Vertebral infections, including vertebral osteomyelitis, septic physitis, and discospondylitis, are rarely reported in goats, and when reported, have been largely limited to necropsy case reports., Objective: Describe clinical findings and outcome in goats with vertebral infections evaluated by computed tomography (CT)., Animals: Five goats with vertebral osteomyelitis, septic physitis, and discospondylitis evaluated by CT., Methods: Retrospective case series., Results: The most common presenting complaints were progressive weakness, paresis and recumbency. Three goats were tetraparetic and 2 goats had pelvic limb paraparesis. Clinicopathologic findings included leukocytosis, mature neutrophilia, and hyperfibrinogenemia. The most common vertebrae affected were C7-T1. All 5 goats had discospondylitis with or without vertebral osteomyelitis and septic physitis. Computed tomographic evidence of spinal cord compression was present in 4/5 goats. Medical management (antimicrobials, physical therapy, analgesia, supportive care) was attempted in 4 goats, and 1 goat was euthanized at the time of diagnosis. All 4 goats that were treated regained ambulatory ability and survived to hospital discharge., Conclusions and Clinical Importance: Despite severity of CT imaging findings, goats with discospondylitis, septic physitis, and vertebral osteomyelitis can successfully return to ambulatory function. Additional studies are required to determine ideal treatment regimens., (© 2024 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals LLC on behalf of American College of Veterinary Internal Medicine.)

BACKGROUND Infantile spondylodiscitis is a rare condition with a varied clinical presentation. Microbial infection may not always be identified, but early diagnosis and management are required to prevent long-term and irreversible complications, including spinal deformities and vertebral instability. CASE REPORT This report is of a 21-month-old girl with a 3-week history of difficulty in walking and constipation due to L1-L2 spondylodiscitis following a gluteal skin burn. The family had sought medical advice multiple times, but results of all investigations were unremarkable. Her initial spine X-ray was negative but her spine magnetic resonance imaging (MRI) showed a picture suggestive of spondylodiscitis, which then responded to empiric treatment with broad-spectrum antibiotics. The patient showed complete resolution of clinical symptoms and her bowel habits came back to normal after 6 months of complete antibiotics treatment. Her repeat spine MRI showed a significant improvement of her spondylodiscitis. CONCLUSIONS This report has highlighted the importance of rapid diagnosis and management of infantile spondylodiscitis and the challenging approach to treatment when no infectious organism can be identified, as well as the early initiation of antibiotics therapy when appropriate in pediatric patients to avoid serious neurological complications associated with spondylodiscitis. Thus, it is essential to assess children with refusal to walk, gait problems, or back discomfort, especially when they are associated with high inflammatory markers.

Native vertebral osteomyelitis, also termed spondylodiscitis, is an antibiotic-resistant disease that requires long-term treatment. Without proper treatment, NVO can lead to severe nerve damage or even death. Therefore, it is important to accurately diagnose the cause of NVO, especially in spontaneous cases. Infectious NVO is characterized by the involvement of 2 adjacent vertebrae and intervertebral discs, and common infectious agents include Staphylococcus aureus, Mycobacterium tuberculosis, Brucella abortus, and fungi. Clinical symptoms are generally nonspecific, and early diagnosis and appropriate treatment can prevent irreversible sequelae. Advances in pathologic histologic imaging have led physicians to look more forward to being able to differentiate between tuberculous and septic spinal discitis. Therefore, research in identifying and differentiating the imaging features of these 4 common NVOs is essential. Due to the diagnostic difficulties, clinical and radiologic diagnosis is the mainstay of provisional diagnosis. With the advent of the big data era and the emergence of convolutional neural network algorithms for deep learning, the application of artificial intelligence (AI) technology in orthopedic imaging diagnosis has gradually increased. AI can assist physicians in imaging review, effectively reduce the workload of physicians, and improve diagnostic accuracy. Therefore, it is necessary to present the latest clinical research on NVO and the outlook for future AI applications.

Background : The incidence of pyogenic spondylodiscitis has been increasing in countries of Europe and North America, probably due to an increasing number of persons with risk factors for this infection. It is unclear whether HIV infection in the era of antiretroviral therapy (ART) increases the risk for spondylodiscitis. Method : We present 7 cases of pyogenic spondylodiscitis of the cervical, thoracic, and lumbar spine in six individuals living with HIV under ART with suppressed viral load. Results : All patients presented with severe non-radicular pain and elevated inflammatory markers. Diagnosis was confirmed by magnetic resonance imaging (MRI) scan and isolation of the pathogen. Staphylococcus aureus was the causative pathogen in five patients. One patient suffered from an infection with Klebsiella pneumoniae followed by a mixed infection with Cutibacterium acnes and Bacillus circulans 18 months later. All patients needed surgical intervention, and the mean duration of antibiotic treatment was 17 weeks (range 12-26). Five patients recovered fully, including two persons who also suffered from endocarditis. One patient died from multi-organ failure. Conclusion : Spondylodiscitis may be seen more frequently in persons living with HIV as they grow older and suffer from comorbidities which put them at risk for this infection. HIV physicians should be aware of the infection and its risk factors., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Non-specific features of spondylodiscitis lead to a delay and challenge in the diagnosis/differential diagnosis/treatment processes, and thus, serious complications may arise. This study aims to compare brucellar, pyogenic, and tuberculous types of spondylodiscitis, considering their demographic, clinical, and laboratory differences. This may provide more rapid management and good outcomes., Patients and Methods: A total of 131 patients with infectious spondylodiscitis were included in the study. The patients were divided into brucellar (n=63), pyogenic (n=53), and tuberculous (n=15) types of spondylodiscitis and compared for demographic, clinical, laboratory, and imaging features., Results: Tuberculous spondylodiscitis had higher scores for weight loss, painless palpation, thoracic spine involvement, and psoas abscess formation than other spondylodiscitis. Also, tuberculous spondylodiscitis had higher rates of neurologic deficit and lower rates of lumbar involvement than brucellar spondylodiscitis. Pyogenic spondylodiscitis is more likely to occur in patients who have a history of spine surgery compared to other forms of spondylodiscitis. Also, pyogenic spondylodiscitis had higher rates of fever, erythema, paraspinal abscess, white blood cell (WBC), and erythrocyte sedimentation rate (ESR) than brucellar spondylodiscitis. On the other hand, brucellar spondylodiscitis had higher rates of rural living and sweating than pyogenic spondylodiscitis., Conclusions: Weight loss, painless palpation, involved thoracic spine, psoas abscess, and neurologic deficit are symptoms favoring tuberculous spondylodiscitis. History of spine surgery, high fever, skin erythema, and paraspinal abscess are findings in favor of pyogenic spondylodiscitis. Rural living, sweating, and involved lumbar spine are symptoms that indicate brucellar spondylodiscitis. These symptoms can be used to distinguish the types of spondylodiscitis.

Background: Patients in low- and middle-income countries (LMICs) have substantial treatment abandonment and non-adherence with outpatient oral medications. This work sought to investigate outcomes of postoperative discitis treated with debridement and a novel technique focused on reducing outpatient antibiotic requirement in an LMIC setting., Methods: This study, conducted and reported following STROBE guidelines, reviewed outcomes of all patients with postoperative discitis who had been debrided by 1 neurosurgeon in a resource-limited setting during 2008-2020. Patients had undergone single-level L4-L5 or L5-S1 discectomy elsewhere, later developing magnetic resonance imaging-confirmed discitis. After non-response or deterioration following intravenous antibiotics, patients underwent early debridement, followed by in-patient antibiotic instillation into disc space for 2 weeks via drain. Study outcomes were modified Kirkaldy-Willis Grade, Japan Orthopaedic Association (JOA) score, and visual analog scale (VAS) score, all assessed at 1 year., Results: Twelve patients were included, 10 male and 2 female, with median age of 46 (IQR 3.5) years. Debridement was done after median 82.5 (IQR 35) days and took median time of 105 (IQR 17.5) minutes. VAS scores (mean ± SD) decreased from 9.25 ± 0.75 preoperatively to 0.67 ± 0.89 1 year postoperatively (mean difference 8.58, 95% CI 8.01-9.15, P < 0.001). JOA scores (mean ± SD) improved from 4.5 ± 2.94 to 26.42 ± 1.31 1 year postoperatively (mean difference 21.92, 95% CI 20.57-23.26, P < 0.001). Kirkaldy-Willis grade was excellent in 6 (50%) patients, good in 5 (41.7%), and fair in 1 (8.3%). Patients became ambulatory within 2 weeks, with no major complications during 4.15 (IQR 3.45) years of median follow-up., Conclusions: In LMICs, patients with medically refractory postoperative discitis potentially have good outcomes after debridement plus 2-week local antibiotic instillation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Spinal infection caused by Parvimonas micra ( P. micra ) is a rare infection. The characteristic imageology includes spondylodiscitis, spondylitis, paravertebral abscess, and epidural abscess. One case of spondylodiscitis of lumbar complicated with spinal epidural abscess caused by P. micra was admitted to the Department of Spinal Surgery, Xiangya Hospital, Central South University on February, 2023. This case is a 60 years old man with lower back pain and left lower limb numbness. MRI showed spondylitis, spondylodiscitis, and epidural abscess. The patient underwent debridement, decompression and fusion surgery. The culture of surgical sample was negative. P. micra was detected by metagenomic next-generation sequencing (mNGS). The postoperative antibiotic treatment included intravenous infusion of linezolid and piperacillin for 1 week, then intravenous infusion of ceftazidime and oral metronidazole for 2 weeks, followed by oral metronidazole and nerofloxacin for 2 weeks. During the follow-up, the lower back pain and left lower limb numbness was complete remission. Spinal infection caused by P. micra is extremely rare, when the culture is negative, mNGS can help the final diagnosis.

Spinal infection comprises pyogenic and non-pyogenic spondylodiscitis. This condition may manifest with non-specific clinical symptoms, elevated infective parameters and imaging findings that are difficult to distinguish. The cornerstone of a definitive diagnosis and subsequent successful treatment lies in tissue analysis through culture and histopathological studies. In this context, we present a case of Salmonella pyogenic spondylodiscitis affecting the C5/C6 vertebrae, complicated by Salmonella bacteraemia and characterised by mechanical neck pain that curtails daily activities and overall functioning, although without neurological deficits. The uniqueness of this case stems from its occurrence in an immunocompetent individual from a non-endemic area, with no identifiable sources of Salmonella infection or preceding gastrointestinal symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Mycobacterium xenopi is a non-tuberculous mycobacterium (NTM) that sporadically causes infections in humans and can cause rare bone and joint infections in immunocompromised hosts with history of spinal surgery. This slow-growing mycobacterium takes 8-12 weeks to grow on culture. Metagenomic next-generation sequencing (MNGS) is a highly sensitive and specific plasma-based microbial cell-free DNA test that can detect M. xenopi weeks prior to culture growth. We present a case of M. xenopi lumbosacral discitis with presacral abscess in an immunocompromised woman without history of spinal surgery which was detected by MNGS 8 weeks prior to culture growth. The patient's discitis resolved with an M. xenopi -directed regimen of ethambutol, rifampin and azithromycin. This case illustrates the utility of next-generation sequencing tests in rapid diagnosis of rare and opportunistic infections, as compared with traditional diagnostic tests, with supporting contextual clinical and diagnostic findings., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Most osteoarticular infections (OAI) occur via the hematogenous route, affect children under 5 years of age old, and include osteomyelitis, septic arthritis, osteoarthritis and spondylodiscitis. Early diagnosis and prompt treatment are needed to avoid complications. Children with suspected OAI should be hospitalized at the start of therapy. Surgical drainage is indicated in patients with septic arthritis or periosteal abscess. Staphylococcus aureus is implicated in OAI in children at all ages; Kingella kingae is a very common causative pathogen in children from 6 months to 4 years old. The French Pediatric Infectious Disease Group recommends empirical antibiotic therapy with appropriate coverage against methicillin-sensitive S. aureus (MSSA) with high doses (150 mg/kg/d) of intravenous cefazolin. In most children presenting uncomplicated OAI with favorable outcome (disappearance of fever and pain), short intravenous antibiotic therapy during 3 days can be followed by oral therapy. In the absence of bacteriological identification, oral relay is carried out with the amoxicillin/clavulanate combination (80 mg/kg/d of amoxicillin) or cefalexin (150 mg/kg/d). If the bacterial species is identified, antibiotic therapy will be adapted to antibiotic susceptibility. The minimum total duration of antibiotic therapy should be 14 days for septic arthritis, 3 weeks for osteomyelitis and 4-6 weeks for OAI of the pelvis, spondylodiscitis and more severe OAI, and those evolving slowly under treatment or with an underlying medical condition (neonate, infant under 3 months of old, immunocompromised patients). Treatment of spondylodiscitis and severe OAI requires systematic orthopedic advice., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Dysregulated systemic immune responses during infectious spondylodiscitis (IS) may impair microbial clearance and bone resorption. Therefore, the aim of the study was to examine whether circulating regulatory T cells (Tregs) are elevated during IS and whether their frequency is associated with alterations in T cells and the presence of markers of bone resorption in the blood. A total of 19 patients hospitalized with IS were enrolled in this prospective study. Blood specimens were obtained during hospitalization and 6 weeks and 3 months after discharge. Flow cytometric analysis of CD4 and CD8 T cell subsets, the percentage of Tregs and serum levels of collagen type I fragments (S-CrossLap) were performed. Out of 19 enrolled patients with IS, microbial etiology was confirmed in 15 (78.9%) patients. All patients were treated with antibiotics for a median of 42 days, and no therapy failure was observed. Next, a significant serum C-reactive protein (S-CRP) decrease during the follow-up was observed, whereas the frequencies of Tregs remained higher than those of controls at all-time points (p < 0.001). In addition, Tregs demonstrated a weak negative correlation with S-CRP and S-CrossLap levels were within the norm at all-time points. Circulating Tregs were elevated in patients with IS and this elevation persisted even after the completion of antibiotic therapy. Moreover, this elevation was not associated with treatment failure, altered T cells, or increased markers of bone resorption., Competing Interests: Declaration of Competing Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023. Published by Elsevier B.V.)

BACKGROUND. The reported sensitivity and yield of image-guided biopsies for diskitis-osteomyelitis vary widely. OBJECTIVE. The purpose of this study was to perform a systematic review of the literature and meta-analysis of pooled sensitivity data to elucidate strategies for optimal image-guided biopsies among patients suspected to have diskitis-osteomyelitis. EVIDENCE ACQUISITION. A comprehensive literature search was performed for studies of patient populations with proven or suspected diskitis-osteomyelitis that included percutaneous image-guided biopsy as part of the workup algorithm. Type of pathogens, imaging modality used for biopsy guidance, tissue targeted, antibiotic administration at the time of biopsy, true microbiology positives, true microbiology negatives, false microbiology positives, false microbiology negatives, disease (i.e., diskitis-osteomyelitis) positives as determined by reference standard, true infection positives (i.e., positive microbiology or pathology results), and total number of biopsies performed were extracted from the studies. Microbiology sensitivity, microbiology biopsy yield, and infection sensitivity were calculated from the pooled data. These terms and the data required to calculate them were also defined in detail. EVIDENCE SYNTHESIS. Thirty-six articles satisfied inclusion criteria and were used for analysis. The pooled microbiology sensitivity, infection sensitivity, and microbiology biopsy yields were 46.6%, 70.0%, and 26.7%, respectively. Mycobacterium tuberculosis-only microbiology sensitivity was significantly higher than both pyogenic bacteria and mixed-organism microbiology sensitivity ( p < .001). Staphylococcus aureus was the most common causative organism (28.6%). Pooled microbiology sensitivity was not significantly different for CT guidance and fluoroscopy guidance ( p = .16). There was a statistically significant difference between pooled microbiology sensitivity of bone/end plate (45.5%) and disk/paravertebral soft-tissue (64.8%) image-guided biopsies ( p < .001). There was no statistically significant difference in pooled microbiology sensitivities for patients who received antibiotics before the procedure (46.2%) and those who did not (44.6%) ( p = .70). CONCLUSION. Image guidance by CT or fluoroscopy does not affect microbiology yield, disk and paravertebral soft-tissue biopsies should be considered over bone and end plate biopsies, and preprocedural antibiotic administration does not appear to impact biopsy results. CLINICAL IMPACT. Understanding and correctly applying reported statistics contribute to appropriate interpretation of the abundant literature on this topic and optimization of care for patients with diskitis-osteomyelitis.

Background: Disseminated nocardiosis is a very rare disease. By now only few cases of meningitis and spondylodiscitis have been reported. To our knowledge, this is the first case of meningitis caused by Nocardia nova., Case Presentation: We report on a case of bacteraemia, meningitis and spondylodiscitis caused by N. nova in an immunocompetent patient. We describe the long, difficult path to diagnosis, which took two months, including all diagnostic pitfalls. After nocardiosis was diagnosed, intravenous antibiotic therapy with ceftriaxone, later switched to imipenem/cilastatin and amikacin, led to rapid clinical improvement. Intravenous therapy was followed by oral consolidation with co-trimoxazole for 9 months without any relapse within 4 years., Conclusions: Establishing a diagnosis of nocardiosis is a precondition for successful antibiotic therapy. This requires close communication between clinicians and laboratory staff about the suspicion of nocardiosis, than leading to prolonged cultures and specific laboratory methods, e.g. identification by 16S rDNA PCR., (© 2023. The Author(s).)

Background: Brucellosis is one of the most common zoonotic diseases in the world. Osteoarticular complications, especially vertebral system involvement, are most commonly reported. However, reports and coreports of pulmonary complications and thoracal spondylodiscitis and epidural abscess are rare., Case Presentation: Spondylodiscitis was detected at the T11-12 vertebral level, followed by epidural and paravertebral abscess, and then empyema was detected in a 17-year-old Asian female patient without any additional disease. The patient had used various antibiotics and the disease could not be proven bacteriologically. Also, the Rose Bengal test was negative. However, serologically high titer Brucella positivity was detected in the blood and pleural fluid sample. Drainage was required for bilateral empyema. Disease duration prolonged due to multiple complications. The patient was cured with combined long-term treatment for brucellosis., Conclusions: Although some are rare, brucellosis is a zoonotic disease that can cause many complications. The gold standard for diagnosis is the growth of bacteria in blood culture or tissue culture. However, isolation of the microorganism can be very difficult. Clinical suspicion and serological tests are important guides., (© 2022. The Author(s).)

Background: Human brucellosis is the most frequently contracted zoonotic infection worldwide. Although being an old disease that carries minimal risks of mortality, it remains a source of considerable sequelae and disability. However, noncontiguous multifocal spinal involvement is an exceptional presentation of brucellosis; additionally, an associated paravertebral abscess is extremely rare., Case Presentation: This paper focuses on a 67-year-old Lebanese woman with noncontiguous multifocal Brucella spondylodiscitis, involving the T12-L1 and L3-L4 segments, with paravertebral abscess formation. She presented with a 3-week history of acute severe lumbar back pain, radiating to the lower extremities and associated with impaired mobility and lower extremity weakness. The patient complained of night sweating but had no fever. No lymphadenopathy, hepatomegaly, or splenomegaly could be observed. She had painful percussion of the lumbar spine, painful passive mobilization, and paravertebral tenderness, yet her neurological examination was completely normal. BrucellaCapt test was positive at a titer of 1/5120 (reference range 1/180). The patient was treated with an inpatient regimen for 2 weeks, which was followed by an outpatient oral antibiotic regimen with doxycycline, rifampin, and ciprofloxacin to complete a total treatment duration of 3 months. Magnetic resonance imaging was performed at the end of the treatment and showed a complete resolution of the paravertebral abscess., Conclusion: Noncontiguous multifocal Brucella spondylodiscitis with paravertebral abscess is an extremely rare presentation. It may be effectively managed by antibiotic therapy, without surgery or drainage, in the absence of neurological complications. Nonetheless, the principal challenge to an efficient management is establishing the diagnosis of Brucella in the first place. In endemic countries, a strong suspicion of spinal involvement of brucellosis should be elicited in front of back pain presentations-even in the absence of fever and other related symptoms., (© 2022. The Author(s).)

Dalbavancin is a novel lipoglycopeptide antibiotic, characterized by a broad spectrum of activity against Gram-positive cocci. However, its efficacy in spondylodiscitis treatment is not fully established. All adult patients diagnosed with spondylodiscitis and treated with dalbavancin were included across four Italian medical centers from January 2018 to April 2021. We collected clinical and laboratory data, and presented follow-up findings along with a thorough literature review. 13 patients (mean age= 65 years) were included in this study. Dalbavancin was administered as first line treatment in six (46%) of the patients. Reasons for using Dalbavancin included treatment simplification (62%) and clinical failure of previous antibiotics (23%). In general, Dalbavancin was well tolerated with minimal adverse events, and clinical success was achieved in 11/13 (85%) of the patients during hospitalization with additional antibiotics required in the remaining two cases. Five months after discharge, no mortality was observed, however, 42% of patients required additional antibiotics for signs of infection on follow-up imaging. Our study suggests that Dalbavancin could be an effective and safe option in treating spondylodiscitis, however, the scarcity of studies on the topic is concerning. Thus, further studies with large samples and long-term follow-up are warranted to compare the efficacy of Dalbavancin with other available treatment options.

Background: Spondylodiscitis is a severe condition where standalone antibiotic therapy resolves most cases. In refractory infections, open surgery may aid with infection debulking. However, significant morbidity can occur. Nowadays, endoscopic approaches are emerging as an alternative. However, until now, only small-scale studies exist. Being so, we carried the first systematic review on spondylodiscitis endoscopic debridement indications, technique details, and outcomes., Methods: Search for all English written original studies approaching the spondylodiscitis endoscopic treatment was performed using PubMed and EBSCO host. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a pre-specified protocol was registered at PROSPERO (CRD42020183657)., Results: Fourteen studies involving 342 participants were included for analysis. Data overall quality was fair. Indications for the endoscopic approach were poorly defined. The most consensual indication was refractory infection to conservative treatment. Spinal instability or neurological deficits were common exclusion criteria. All authors described similar techniques, and despite the frequent severe co-morbidities, procedure morbidity was low. Re-interventions were common. Microorganism identification varied from 54.2 to 90.4%. Treatment failure among studies ranged from 0 to 33%. Pain, functional status, and neurological deficits had satisfactory improvement after procedures., Conclusions: The endoscopic debridement of spondylodiscitis seems to be an effective and safe approach for refractory spondylodiscitis. A novel approach with initial endoscopic infection debulking and antibiotic therapy could improve the success of spondylodiscitis treatment., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Research Question: In pyogenic spondylodiscitis, infections with coagulase-negative staphylococci must be given increasing importance. Empirical antibiosis is particularly necessary in patients with severe or progressive neurological deficits or hemodynamic instability, as well as in the case of culture-negative spondylodiscitis. It is unclear whether uniform empirical antibiosis standards adapted to the resistance profiles exist in Germany., Study Design and Methods: A survey on the empirical antibiotic therapy for pyogenic spondylodiscitis was conducted at German university and Berufsgenossenschaft clinics, each in the departments of orthopedics and trauma surgery. The survey results were applied to the resistance profiles of pathogens in 45 spondylodiscitis patients treated in our department between 2013 and 2020. Thus, the potential susceptibility and resistance rates were calculated for the indicated antibiotic therapies., Results: Of the 71 clinics queried, a total of 44 (62.0%) responded. Sixteen different antibiotic therapies were reported as standard regimes. Among these, 14 different combination therapies were reported. The most commonly reported empirical antibiotics, namely amoxicillin/clavulanic acid or ampicillin/sulbactam (29.5%) and cephalosporins (18.2%) showed high potential resistance rates of 20.0% and 35.6%, respectively, in relation to the previously published resistance profile. The highest potential susceptibility rates were achieved with a combination of vancomycin + ampicillin/sulbactam (91.1% sensitive pathogens), vancomycin + piperacillin/tazobactam (91.1% sensitive pathogens), and ampicillin/sulbactam + teicoplanin (95.6% sensitive pathogens). One out of these combinations was reported as standard regime by three clinics (6.8%)., Conclusion: The nationwide survey of empiric antibiotic treatment for pyogenic spondylodiscitis revealed a large heterogeneity in the standard of care. A combination of a broad-spectrum-β-lactam antibiotic with an additional glycopeptide antibiotic may be justified., (© 2022. The Author(s).)

Background: Pediatric spondylodiscitis is rare, hardly diagnosed and treated due to the nonspecificity of clinical presentation and laboratory investigations, difficulty of etiologic identification and lack of management guidelines., Methods: A retrospective study was conducted on 29 children with spondylodiscitis. Clinical, hematic and radiologic data were collected and compared between 2 age-subgroups (below and from 4 years old on) to investigate age-related differences. Epidemiologic, management and follow-up data were also described., Results: Slight male predominance and a peak of incidence <2 years were observed. Symptoms were significantly differently distributed in the 2 age-subgroups: children <4 years showed mainly refusal/inability to sit or bear weight, irritability, limping and poor general conditions; children ≥4 years most frequently had back pain and fever, and pain upon palpation of the spine. The lumbar spine and more than 1 vertebra were most frequently involved. Median diagnostic delay of 12 days was observed, without significant difference between age-subgroups, and delay >2 months was always associated with multivertebral involvement and complications. All children were treated with broad-spectrum antibiotics for a median of 12 weeks. Only in 1 complicated case, surgical treatment was also required., Conclusions: The clinical presentation of spondylodiscitis may be age-specific, with younger children often exhibiting subtle signs and symptoms. Broad-spectrum antibiotics covering for Staphylococcus aureus should be initiated as soon as possible and performed many weeks, being effective in treating the infection without clinical sequelae, even in patients with comorbidities. Surgical treatment should be reserved for complicated cases with neurologic involvement., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The incidence of extra pelvic infections due to vaginal microflora bacteria has increased as growth media and methods of isolation have improved. However, bone infections seem to be still relatively rare, and little is known about their risk factors, clinical presentation, treatment and final outcome. We describe here a spondylodiscitis due to Gardnerella vaginalis, Atopobium vaginae, Peptostreptococcus indolicus and Prevotella amnii, anaerobic bacteria from vaginal microbiota. Our patient had no obvious predisposing factor and recovered after antibiotic treatment. To our knowledge, this case is the first reported spondylodiscitis caused by polymicrobial vaginal flora in a healthy, immunocompetent woman., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aims: Flucloxacillin is a frequently used antibiotic in the treatment of spondylodiscitis. We assessed steady-state concentrations and time above minimal inhibitory concentration (fT > MIC) of flucloxacillin in the intervertebral disc, vertebral cancellous bone, subcutaneous tissue and plasma, after intravenous and oral administration., Methods: Sixteen pigs were randomized into two groups; Group Peroral (Group PO) and Group Intravenous (Group IV) received 1 g flucloxacillin every 6 h for 24 h orally or intravenously. Microdialysis was used for sampling in the compartments of interest. A flucloxacillin target of 50% fT > MIC was applied for three MIC targets: 0.125, 0.5 and 2.0 μg/mL., Results: Intravenous administration resulted in significantly longer fT > MIC for all targets. Target attainment was only reached for the low target of 0.125 μg/mL in Group IV in vertebral cancellous bone, subcutaneous tissue, and plasma (intervertebral disc 47%). In Group IV, mean fT > MIC values in the investigated compartments were in the range of 47-67% of the dosing interval for 0.125 μg/mL, 20-35% for 0.5 μg/mL, and 0-15% for 2.0 μg/mL. In Group PO, mean fT > MIC values for 0.125 μg/mL were in the range of 1-33%. No pigs reached a concentration of 0.5 μg/mL in any of the investigated compartments in Group PO., Conclusion: Administration of 1 g flucloxacillin every 6 h resulted in surprisingly low steady-state fT > MIC after intravenous and oral administration. However, intravenous administration resulted in significantly higher concentrations across compartments compared to oral administration. Sufficient target tissue concentrations for treatment of spondylodiscitis may require a dose increase or alternative dosing regimens., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Veillonella species are an opportunistically pathogenic commensal anaerobic Gram-negative coccus commonly found in the oral, genitourinary, respiratory, and intestinal tract of humans and some animals. Infection is rare, even in immunocompromised hosts, and has been identified to cause a wide array of different infections, including endocarditis, osteomyelitis, and meningitis., Case Presentation: An 82-year-old Caucasian male retired ex-gymnast presented to the emergency department with a 2-week history of acute on chronic lower back pain without clear precipitant. He displayed no systemic symptoms, and had not sustained any recent injuries. Initial blood and radiological investigation did not reveal an infective or mechanical cause for his pain; however, a few days into admission, he developed a fever and signs of sepsis. A thorough septic screen was performed, including a spinal magnetic resonance imaging scan, which did not reveal any abnormalities. Blood cultures revealed Veillonella parvula bacteremia, with subsequently repeated magnetic resonance imaging displaying rapid disseminated infection including bilateral psoas abscess, discitis, and osteomyelitis. Infective endocarditis was later identified with echocardiogram. He received intravenous ceftriaxone and later oral amoxicillin and clavulanic and recovered on 6-month follow-up., Conclusions: This case illustrates the potential pathogenicity and unexpected rapid course of Veillonella parvula infection even in an immunocompetent host presenting with back pain. This case highlights the critical importance of a thorough septic screen when investigating patients for early signs of sepsis., (© 2022. The Author(s).)

Background: Various surgical techniques for treating spondylodiscitis have been proposed, but the optimal surgical treatment remains controversial. In this study, we propose a new procedure that is implanting antibiotic-loaded calcium sulfate (CS) beads into the disc after debridement using the Quadrant channel combined with percutaneous fixation through a single-stage posterolateral approach for the treatment of spondylodiscitis. Thus, the purpose of this study is to assess the safety and efficacy of this procedure., Methods: This study collected the data of 32 patients with spine spondylodiscitis and was surgically treated in our department from July 2015 to August 2020. The Demographic data included age, gender, involved segment, and complications were collected. The intra-operative details, results of culture, functional outcome, radiologic outcome, and length of hospital stay, laboratory examination were recorded., Results: The mean age of the 32 patients was 61.1 ± 9.7 years old. The mean operative time was 135.0 ± 30.6 minutes, and the mean blood loss was 243.4 ± 92.1 ml. The positive rate of culture was 72%. The mean Visual analogue scale (VAS) and Oswestry Disability Index (ODI) score significantly improved from 7.5 to 1.6 and from 65% to 10%. Cobb angle was significantly improved and could be maintained at final follow-up. New bone formation was observed in all patients. There were no recurrences of infection in our study., Conclusions: The posterolateral debridement and percutaneous fixation combined with antibiotic-loaded calcium sulfate beads filling are effective in the treatment of spondylodiscitis in terms of infection control, early mobilization, and recovery., (© 2022. The Author(s).)

Introduction: Infectious spondylodiscitis is a rare infection of the intervertebral disc and the adjacent vertebral bodies that often disseminates and requires long-term antibiotic therapy. Immunologic profiling of patients with infectious spondylodiscitis could allow for a personalized medicine strategy. We aimed to examine the induced immune response in patients with infectious spondylodiscitis during and after antibiotic therapy. Furthermore, we explored potential differences in the induced immune response depending on the causative pathogen and the dissemination of the disease., Methods: This was a prospective observational cohort study that enrolled patients with infectious spondylodiscitis between February 2018 and August 2020. A blood sample was collected at baseline, after four to six weeks of antibiotic therapy (during antibiotic therapy), and three to seven months after end of antibiotic therapy (post-infection). The induced immune response was assessed using the standardized functional immune assay TruCulture ® . We used a panel of three immune cell stimuli (lipopolysaccharide, Resiquimod and polyinosinic:polycytodylic acid) and an unstimulated control. For each stimulus, the induced immune response was assessed by measuring the released concentration of Interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12p40, IL-17A, Interferon-γ (IFN-γ) and Tumor necrosis factor-α (TNF-α) in pg/mL., Results: In total, 49 patients with infectious spondylodiscitis were included. The induced immune responses were generally lower than references at baseline, but the cytokine release increased in patients after treatment with antibiotic therapy. Post-infection, most of the released cytokine concentrations were within the reference range. No significant differences in the induced immune responses based on stratification according to the causative pathogen or dissemination of disease were found., Conclusion: We found lower induced immune responses in patients with infectious spondylodiscitis at baseline. However, post-infection, the immune function normalized, indicating that an underlying immune deficiency is not a prominent factor for spondylodiscitis. We did not find evidence to support the use of induced immune responses as a tool for prediction of the causative pathogen or disease dissemination, and other methods should be explored to guide optimal treatment of patients with infectious spondylodiscitis., Competing Interests: SN received an unrestricted research grant from the Novo Nordic Foundation. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Loft, Møller, Thudium, Knudsen, Ostrowski, Andersen and Nielsen.)

Spinal epidural abscess (SEA) is a rare but severe infection with potentially devastating consequences. Epidural abscesses caused by Salmonella serogroup C2 are even rarer and tend to be more invasive with multidrug resistance. Early diagnosis, effective use of antibiotics and surgical intervention are the mainstay strategies for managing SEA, especially for more virulent and multidrug-resistant Salmonella infections. This case report presents a rare case of an elderly and fragile woman with Salmonella spondylodiscitis and an extensive epidural abscess, which were successfully treated with intravenous antibiotics and unilateral biportal endoscopic (UBE) debridement and drainage through four small surgical incisions. After surgery, her fever subsided, she regained consciousness and her low back pain dramatically improved. Follow-up magnetic resonance imaging showed complete resolution of the epidural abscess. At 6 months after surgery, the patient regained muscle strength, ambulated with a walker and had no recurrence of the infection. The UBE technique can effectively eradicate infection while minimizing surgery-related risks and complications. A multidisciplinary team is required to achieve a good outcome.

Introduction: Streptococcus suis (S. suis) infection is poorly described zoonosis in our country, which is related with exposure to pigs or their meat. The most common clinical presentation is meningitis, while spine's involvement is rare., Methods: We report 2 cases of S. suis infection and perform a systematic review of the articles published on S. suis spondylodiscitis between January 1994 and May 2020 with the aim of defining the clinical characteristics, predisposing factors and evolution., Results: 17 cases are described, 76.5% males with a mean age of 57.6 years, generally without associated underlying disease. Enolism was a factor present in 17.6%. 70.6% had exposure to pigs or their meat and 20% hand injuries. The mean duration of symptoms was 10.2 days and the most affected segment was the lumbar level. 70.6% had meningitis. All were treated with beta-lactams with an average duration of 53.2 days. There was a recurrence and none died., Conclusion: There are few cases of S. suis spondylodiscitis in the literature. When occurs, it is associated with another type of infection in most cases. They present a good response to medical treatment and a good prognosis., (Copyright © 2021. Published by Elsevier España, S.L.U.)

Background: Infectious spondylodiscitis of the lumbar spine is a common serious disease for which evidence-based therapeutic concepts are still lacking., Objective: This retrospective study compared the impact of the health status of patients on the length of hospital stay with regard to the treatment concept, i.e., antibiotic therapy or antibiotic therapy in combination with fixation surgery., Patients and Methods: The study included 54 consecutive patients with infectious spondylodiscitis of the lumbar spine who had been treated at our clinic between 2004 and 2013. Records included patient demographics, concomitant diseases, the neurological status and treatment modality, and the length of hospital stay., Results: 40 men and 14 women with a mean age of 64.2 (30-89) years were included. 13 patients were only treated with antibiotics (group A), 7 patients with abscess decompression (group B), 18 patients with early dorsal fusion (<10 days after admission) (group C), and 16 patients with late dorsal fusion (≥10 days after admission; group D). Patients undergoing early dorsal fusion had a significantly shorter hospital stay (33.2 days) than patients undergoing late dorsal fusion (57.0 days), P = 0.016. Mean hospital stay of patients treated with antibiotics was 30.3 days, that of patients receiving abscess decompression 57.8 days. Patients receiving only antibiotics had a significantly lower CRP level at admission than patients undergoing early fusion, P < 0.05., Conclusion: Patients with one or more relevant chronic concomitant diseases showed faster recovery, shorter hospital stays, and earlier return to daily routine after early dorsal fusion than after late dorsal fusion or abscess evacuation alone.

Human Brucellosis is a bacterial infection caused by species of Brucella, which can involve multiple organs and tissues. Spinal epidural abscesses are rare and may be complicated by potentially life threatening neurological or vascular compromise. We report a 21-year-old female with spinal brucellosis complicated by lumbar spondylodiscitis, epidural abscess and a large right-sided paraspinal abscess extended from L4 to sacrum. The diagnosis was based on laboratory and magnetic resonance imaging results, symptoms and her occupation. Ultrasound guided needle aspiration and percutaneous abscess drainage was performed, followed by 8 weeks of combination antibiotic therapy. Our therapeutic strategy in this rare case can cause us to reach a greater clearance rate of the infection.

Competing Interests: The authors declare no conflict of interest.

A fifty-three year-old military patient, presented with a 3 months neck pain and paraesthesia of upper right extremity after gastroscopy. Radiological examination demonstrated anuncertain degenerative/infective involvement of C6-C7 intervertebral disc. The patient underwent anterior debridement with C5-C6 disc excisional biopsy, with microbiological findings of Bacillus pumilus with high bacterial concentration. After biopsy, segment arthrodesis was achieved only with vertebral plate cruentation and 3 months of cervical collar. He completed a six-weeks course of intravenous antibiotics for the treatment of atypical spondylodiscitis. At one year of follow-up, he had no residual neck pain or neurological signs or symptoms.