Introduction. Spondylodiscitis is a combination of discitis and spondylitis. It is very rare to have an isolated discitis without associated vertebral osteomyelitis. It is relatively uncommon in developed nations. However, this disease can lead to severe disability and even death if left untreated. Antibiotics is the mainstay of treatment but cases with neurological compromise would need prompt surgical decompression and stabilisation. Recovery in serious cases is often a lengthy process, requiring long hospital stay. Our unit conducted a review as it is noted spondylodiscitis is becoming more common in elderly and immunocompromised groups. Patients and methods. Retrospective study of spondylodiscitis presented to our unit over the last three years is conducted. Medical records and charts are reviewed, with a focus on disease presentation, risk factors, causative organisms and when surgery becomes necessary. Results. 61 cases are identified, average age 62. Lumbar vertebrae is the most affected region (36%), 15% showed multi-level involvement. Back pain presented in all cases. 75% have at least 1 risk factor. Micro-organisms isolated were Staphylococcus aureus (24.6%), coagulase negative staphylococci (9.8%), methicillin resistant S. Aureus (6.6%), Escherichia coli (6.6%) and mycobacterium tuberculosis (3.3%) and no organism found in 16.4%. 31% of cases required surgical intervention due to neurological deficit or vertebral collapse. 69% were managed conservatively The average inpatient stay was 50 days. CRP decreased as symptoms improve. There is no mortality in this series. Conclusions. We noted a higher than usual presentation of spondylodiscitis in vulnerable patients in our region, often presented late. It is important to recognise this disease early. Once established, patients often require long hospital stay to control disease and regain mobilitiy, even when outpatient anti-biotic therapy is available. A multidisciplinary team approach would be beneficial for the recovery process

Aim. Pyogenic spondylodiscitis remains a therapeutic challenge, as demonstrated by divergent treatment guidelines. The combination of moxifloxacin and rifampicin may be an attractive treatment option for cases caused by staphylococci; however, previous studies have reported a reduction in plasma concentrations of moxifloxacin when co-administered with rifampicin. The magnitude of this reduction in spinal tissues is not known. We aimed to investigate the interaction of rifampicin on moxifloxacin tissue concentrations in vertebral cancellous bone, intervertebral disc and subcutaneous adipose tissue in steady-state conditions using microdialysis in a porcine model. Method. Twenty female pigs were randomized into two groups of ten pigs: Group A received moxifloxacin 400 mg orally once daily for three days preoperatively. Group B received moxifloxacin 400 mg orally for three days preoperatively combined with rifampicin 450 mg twice daily for seven days preoperatively. Measurements were obtained from plasma, vertebral cancellous bone, intervertebral disc and subcutaneous adipose tissue for 24 h. Microdialysis was applied for sampling in solid tissues. Results. Co-administration of moxifloxacin and rifampicin demonstrated a reduction of free moxifloxacin concentrations in spinal tissues. The peak drug concentration (C. max. ) and the area under the concentration-time curve (AUC. 0–24. ) in all tissue compartments decreased in the range of 66–79% and 65–76%, respectively. Conclusions. Using microdialysis, we demonstrated a significant reduction of moxifloxacin C. max. and AUC. 0–24. in the spinal tissues when co-administered with rifampicin. Further studies are warranted to understand the clinical implications of this finding for the treatment of pyogenic spondylodiscitis

Aim. Empiric antibiotic therapy for suspected pyogenic spondylodiscitis (SD) should be initiated immediately with severely ill patients and may also be necessary for culture-negative SD. The aim of this study was to infer an appropriate empiric antibiotic regimen by analyzing the antimicrobial susceptibility of isolated pathogens from microbiologically proven pyogenic spondylodiscitis. Method. We performed a retrospective review of adult patients with clinically proven SD treated at our level 1 trauma center between 2013 and 2020. Demographic data, radiologic findings, and treatment modalities were evaluated. The appropriateness of empiric antibiotic regimens was assessed based on the antibiograms of the isolated pathogens. Anamneses were used to distinguish between community-acquired (CA) and healthcare-associated (HA) pathogens, which included cases that had a hospital stay or invasive intervention in the past 6 months. Results. A total of 155 patients (male: N=88; female: N=67; mean age 66.1 ± 12.4 years) with SD were identified. In n= 74 (47.7%) cases, the infections were associated with the healthcare system (HA). N=34 (21.9%) patients suffered from sepsis. The lumbar spine was involved in 47.1% of the cases, the thoracic spine in 37.3%, and the cervical spine in 7.8%. In 7.8% of the cases, SD occurred in multiple spinal segments. N=96 (62.0%) patients were treated surgically. The mean hospital stay was 36.4 ± 36.3 days. Antibiograms of n=45 patients (HA: N=22; CA: N=23) could be retrospectively evaluated: The most frequently identified pathogens were Staphylococcus aureus (46.7%), Coagulase-negative Staphylococci (17.8%), Enterobacteriaceae (15.6%) and Streptococcus species (15.6%). Overall, 82.2% (HA: 68.2%; CA: 95.5%) of the isolated pathogens were sensitive to piperacillin/tazobactam, 77.8% (HA: 81.8%; CA: 72.2%) to vancomycin, 64.4% (HA: 68.2%; CA: 59.1%) to clindamycin, and 55.6% (HA: 36.4%; CA: 72.7%) to ceftriaxone. To a combination of vancomycin plus meropenem 97.8% of pathogens were sensitive (HA: 95.5%; CA: 100.0%), to vancomycin plus ciprofloxacin 91.1% (HA: 86.4%; CA: 95.7%), and to vancomycin plus cefotaxime 93.3% (HA: 90.9%; CA: 95.7%). In 14 cases, empiric antibiosis was adjusted based on the results of the antibiogram. Conclusions. Antibiotic resistance of CA SD pathogens differed significantly from HA SD. The identification of the pathogen and the analysis of its susceptibility guides the antibiotic therapy. Vancomycin in combination with a carbapenem, broad-spectrum cephalosporin, or fluoroquinolone may be appropriate for empiric treatment of HA SD

Aim. Dalbavancin is a lipoglycopeptide with a half-life of 14 days (range 6.1 to 18.4), significantly longer than other antimicrobials, which avoids the need for daily antibiotic dosing. This multi-centre observational study aims to describe the use of dalbavancin to facilitate discharge in treating bone and joint infections. Method. All adult patients treated with dalbavancin from January 2017 to September 2022 in four UK bone infection units were included. Data collected through a standardised data collection form included:. Clinical and microbiological characteristics. Hospital length of stay. Complications. Patient suitability for hypothetical treatment options, such as Outpatient Parenteral. Antibiotic Team (OPAT). Clinical outcome. Treatment-related costs were calculated for dalbavancin and the preferred hypothetical treatment option that would have been administered for the same duration. The costs were subtracted to calculate the cost difference. Clinical success was defined as the absence of definite failure in accordance with the OVIVA Trial protocol. Results. Thirty-six patients were included: 20 males and 16 females, with a median age of 53 (IQR 43–73): Thirteen were septic arthritis, twelve were prosthetic joints, seven were spondylodiscitis and five were other orthopaedic-related implant infections. In twenty cases the infecting organism was Staphylococcus aureus, fourteen were due to coagulase-negative staphylococci and two no cultured organism. Reasons for dalbavancin. The reasons for choosing dalbavancin over alternatives were due to either:. Necessity due to poor adherence (21), or lack of viable OPAT options due to antibiotic resistance or intolerance (7). OR. Convenience to avoid the need for OPAT (8). Dalbavancin was initiated at 1500mg after a median of 12 days (IQR 6–17) of in-hospital antimicrobial therapy. Subsequent dalbavancin doses were based on clinical decisions and ranged from 1000mg to 1500mg. Healthcare benefits. Switching to dalbavancin reduced treatment costs by a median of £3526 (IQR 1118 - 6251) compared with the preferred theoretical alternatives. A median of 31 hospital days (IQR 23–47) was avoided among patients who would have required a prolonged inpatient stay. Outcome. Overall, 20 patients (55.6%) were successfully treated after a median follow-up of 8 months (IQR, 5.8 – 18.4). No patients developed an adverse drug reaction. Conclusions. Dalbavancin can safely facilitate outpatient treatment in patients with limited oral options and in whom OPAT is unsuitable. Dalbavancin is cost-effective compared with the alternative of an inpatient stay

Pyogenic spondylodiscitis is an uncommon but clinically relevant infection that represents 3 to 5% of all cases or osteomyelitis. In Europe, it has an estimated incidence of 0.4 to 2.4/100.000 people/year. Mortality is less than 5%, increasing with a delay in diagnosis greater than 2 month. Patients with renal failure have greater predisposition to infections, consequence of the chronic uremic state. Infection rates in Polytetrafluoroethylene (PTFE) hemodialysis grafts in end-stage renal disease (ESRD) range from 3 to 35%. We present a rare case of concurrent spondylodiscitis and PTFE graft infection in a patient with ESRD and recurrent urinary tract infections (RUTI). The authors present a case of an 80-year-old man with past medical history significant for abdominal aortic aneurysm, bilateral ureter-hydronephrosis, Pseudomonas aeruginosa RUTI and ESRD. Three months after a dialysis PTFE graft hemoaccess was performed a Pseudomonas graft infection was diagnosed and the PTFE graft was removed. One week later, the patient was observed in the author's Department due to an insidious dorsal-lumbar mechanic back pain without neurologic deficits, with progressive deterioration over the past 6 months. A T12-L1 and L1-L2 spondylodiscitis with dural compression was diagnosed and vertebral instability was documented on MRI and TC, demanding surgical treatment. Instrumented fusion with a screw and rod construct was performed from T9 to L5, along with somatic L1 and L2 debridement, and T12-L1 interbody fusion with autograft. Microbiology results were positive for Pseudomonas aeruginosa. Antibotic therapy with ceftazidime (6 weeks) and ciprofloxacin (12 weeks) was performed. Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values. No complications were documented. Four months post-surgery, the patient was asymptomatic (Visual Analogue Scale=0), with no significant limitation in his daily life activity (Disability Rating Index=85) and the vertebral body height was sustained, with imagiological signs of spinal fusion. ESRD patients are more susceptive to infections. Failure in early diagnosis and treatment may lead to disease progression and subsequent functional limitations, deformity and increase in mortality. An aggressive approach, despite delay on diagnosis, is the key factor for a worthy outcome. Despite the good results, recrudescence of spondylodiscitis is known to occur even years after the original offense is treated

To investigate clinical outcome scores in surgically treated patients with either spontaneous or postoperative pyogenic spondylodiscitis after 3, 12 and 24 month. 70 consecutive patients (mean age 64y; male n=33 female n=27) underwent surgical treatment due to pyogenic spondylodiscitis with or without epidural abscess at our department from 2011 to 2013. We performed either microsurgical debridement or debridement in combination with ventral support employing dorsally instrumented spondylodesis followed by bracing and antibiotic therapy up to 12 weeks. European life quality score (EQ-5D), Oswestry disability index (ODI) and visual analogue scale for pain (VAS) were recorded 3, 12 and 24 month after surgery. Length of hospital stay (LOS) was 25,3 days. The Mean time to presentation at our spine center and diagnosis was 3,8 weeks. Distribution of inflammation was lumbar in 66 (94%) and thoracic in 4 (6%) patients. Thirtyfour patients (49%) had isolated spondylodiscitis (SD). Epidural abscess (ED) was found in 26 patients (37%). Ten patients (14%) showed a combination of SD and ED. SD or ED were predominantly found after previous surgery at the same or contiguous level 38 (54%). Nine patients (13%) suffered from ED or SD after previous lumbar epidural steroid injections (LESI). Spontaneous idiopathic inflammation was found only in 13 cases (19%). Standardized follow-up (FU) protocol was scheduled at 3, 12, and 24 month. FU rate was 60%. Healing of the inflammation was the rule. In our study cumulative EQ-5D increased from 0.47 to 0,80. ODI decreased from 41.1 to 24.3 and VAS concerning back pain decreased from 58.4 to 22.6 VAS according sciatica decreased from 46.8 to 20.5. Due to an increasing number of spine surgeries and spinal interventions as well as the increasing age and morbidity of patients, spinal surgeons have to deal more often with the diagnosis pyogenic spondylodiscitis. Standardized conservative or radical surgical treatment strategies in order to achieve good results according to patients life quality are gaining more importance

Spondylodiscitis is a severe infectious disease of the vertebral column and the intervertebral disc space and may be complicated by an epidural abscess. A wide range of pathogens have been described as causative agents. Since several weeks of antibiotics are necessary for successful therapy detection of the causative pathogen is essential. Specific antibiotic therapy improves outcome and reduces antibiotic related complications. Antibiotic Stewardship (ABS) programs are bundled approaches aimed at improving antibiotic therapy. In 2012 an ABS program including weekly interdisciplinary clinical rounds and development of algorithms for diagnosis and therapy of patients with spondylodiscitis was established in the Department of Orthopedic Surgery in a University hospital. We evaluated the effects of ABS with regard to the appropriateness of specimen and pathogen detection and antibiotic therapy in patients with spondylodiscitis. We retrospectively analysed diagnostic procedures and pathogen detection of 100 patients that were hospitalized with spondylodiscitis and compared the data of patients that were treated before (2004–2011) and after introduction of ABS measures (2012–2014). After introduction the effect of ABS on antibiotic therapy was analysed. 100 patients with radiologically confirmed spondylodiscits were enrolled. The pre-ABS group (2004–2011) contained 58 patients. Of these no samples were taken for microbiological examination from 21 patients (36%) and from 8 patients (14%) only swabs were submitted for culture. Aspirates or tissue samples were taken from 22 patients (38%) and blood cultures from 18 patients (31%). Pathogen detection was successful in 18 patients (31%). After introduction of ABS in the beginning of 2012 aspirates or tissue samples were taken from 34 patients (81%) and blood cultures were taken from 34 patients (81%). Pathogen detection was successful in 26 patients (62%). The most commonly detected pathogens were Gram positive cocci (S.aureus, S. epidermidis, and streptococci) in 31 patients. Less common pathogens were found in 12 patients (Gram negative rods (8), fungi (3), Moraxella (1) and Propionibacterium (1). After introduction of ABS antibiotic therapy was changed in 18 of 20 patients (90%) after pathogen identification. In 50 % of cases the inappropriate empiric therapy was changed (MRSA, MRSE and Gram negative rods) and in 50 % broad-spectrum antibiotic therapy could be deescalated. ABS significantly improved the number and quality of samples, increased the number of blood cultures taken and doubled the pathogen detection rates in patients with spondylodiscitis leading to an improvement in antibiotic therapy in almost all patients with pathogen detection

Spondylodiscitis rarely coexists with endocarditis (around 5% of patients with endocarditis). Furthermore, viridans streptococci are not common pathogens of spondylodiscitis and finally the combination of spondylodiscitis and right – sided endocarditis due to viridans streptococci is rare. We present a case of right-sided native valve endocarditis due to Streptococcus mutans presenting as cervical and lumbar spondylodiscitis in a patient with obstructive cardiomyopathy. A 52 year – old man with a history of hypertrophic obstructive cardiomyopathy was admitted with fever and back pain of ten days duration, followed by torticollis. He had undergone dental therapy some weeks before symptom appearance, due to bad oral hygiene, without receiving any chemoprophylaxis. Magnetic resonance imaging revealed L4-L5 and C4-C5 spondylodiscitides. Four blood cultures drawn were all positive for Streptococcus mutans, while fine needle aspiration of the lumbar lesion was unsuccessful. Transesophageal echocardiogram revealed tricuspid and possible pulmonary valve vegetations. The patient was treated with ceftriaxone plus gentamicin for 2 weeks and then ceftriaxone only, for a total of 3 months. He had an uneventful recovery and was referred for cardiosurgical consultation. Physicians managing cases of spondylodiscitides should bear in mind to rule out endocarditis, especially in cases with underlying cardiopathy. The possibility of coexistence is even greater when there is sustained bacteremia and the pathogen isolated from blood cultures is a common pathogen for endocarditis

This study examines the case of a spondylodiscitis in the thoracic spine caused by MRSA which led to two orthopaedic surgeries followed by rehabilitation. A 72.6 year old woman suffered a cutaneous infection with herpes zoster on the right dorsal thorax – 2 weeks later she presented a sepsis by MSSA. 2 month later she lamented sever pain in the thoracic column. She were hospitalized presenting a sepsis by MRSA. One month later it was found an infectious spondylodiscitis from thoracic vertebra T 8 to T 11 with destruction of the intervertebral spaces. To eliminate the infection and stabilize the dorsal column she was undertaken an first orthopaedic surgery by dorsal decompression and dorsal spondylodesis from T 6 – L 2; intraoperative microbiology: MRSA. 3 month later she was undertaken a second surgery by a lateral transthoracic decompression and intervertebral stabilization from T 9 – T 10 with tricortical bone chips and inlay of sponge with Calcibon and Gentamycin. The following rehabilitation took her to a reasonable result. The cost of the first treatment with dorsal stabilization was € 17.694,24, the second surgery was € 13.678,88; the cost of both rehabilitations was € 4.160,00. The finally costs for the whole treatment for the insurance was € 47,442,62. This retrospective case report shows the high costs for a treatment of spondylodiscitis caused by MRSA, not taking in consideration the harm and prolonged pain of the patient

To report a rare case of successfully treated synchronous shoulder septic arthritis, total knee replacement infection and lumbar spondylodiscitis in a patient with rheumatoid arthritis. Fifty-six year old woman, with a history of rheumatoid arthritis diagnosed at twenty-five year old, and total knee replacement at fifty-four. Recently treated with etanercept, presented with acute inflammatory signs of the right shoulder in addition to right knee and lumbar back pain for 6 months. After a shoulder and knee arthrocentesis the diagnosis suspicion of shoulder septic arthritis and total knee replacement infection was confirmed. Therefore it was performed shoulder arthroscopic irrigation and debridement and the first of two stages knee revision, with implantation of antibiotic cement on cement articulating spacer. It was also diagnosed a L1–L2 and L4–L5 spondylodiscitis with dural compression documented on MRI, which determined surgical treatment. By a posterior approach it was performed instrumentation from T11 to L5, followed by L1–L2 and L4–L5 discectomy and interbody fusion with autograft. Shoulder and knee synovial fluid cultures where positive for Methicillin Sensible Staphylococcus aureus narrowing the broad-spectrum combination therapy to levofloxacin for six weeks, with symptomatic relieve and C-reactive protein and white blood cell count returning to normal values. Almost one year down the line the patient remained with no sign of infection, even under the influence of immunosuppressive therapeutic. She returned to her previous status concerning the rheumatologic disease and the second stage knee revision is being planned to happen on the short run. Rheumatoid arthritis patients are a high-risk group for septic arthritis considering, among others, the immunosuppressive therapeutics and the frequent history of arthroplasty. The presented case illustrates three different type of septic complication in the same patient. The timely and aggressive approach was the key factor for a good outcome

We report the clinical features and treatment on a rare case of Candida albicans lumbar spondylodiscitis in a non-immunocompromised patient. Its indolent course leads to delayed suspicion and diagnosis. As soon as fungal infection is suspected investigations with MRI and biopsy should be performed followed by medical therapy. Retrospective data analysis. A 58-year-old male underwent surgery for adenocarcinoma of the ampula of Vater treatment. Subsequently, the patient had a prolonged intensive care unit stay due to major complications, during his stay he developed a septicemia with Candida albicans isolated in the blood work. He received antifungal therapy anidulofungin, later changed to fluconazole during 2 weeks. Repeated blood work were negative and no vegetations on echocardiogram were seen. He was discharged from the ICU to a surgery floor. During the surgical unit stay he presented with lower back pain radiating to the lower limbs. Findings on neurological examination were normal, radiographs of the lumbar spine revealed L5-S1 antero listhesis. He was treated with oral non-steroidal anti-inflammatory drugs and an lumbar MRI and orthopaedic consultation was agended. One month later, after minor trauma he developed myelopathic symptoms with weakness of both lower limbs and severe back pain. Plain radiograph showed anterolistesis worsening. Magnetic resonance imaging showed endplate erosion at L5/S1. There also was evidence of paraspinal collection with epidural compression of the dural sac. The patient was treated surgicaly with debridement and posterior instrumented fusion from L4 to S1. Disk and end-plate material collected confirmed Candidal infection. The patient recovered most of his neurological deficit immediately after surgery. He was subsequently treated during 2 weeks with liposomal amphotericin B, later changed to fluconazole 400mg per os per day. He maintained antifungal therapy during 15 months. He remains asymptomatic with no recurrence of infection clinically or radiologically after surgery. Fungal spondylodiscitis is rare. Sub-acute or chronic low back pain in either immunocompromised or non-immunocompromised patients cronically ill and malnourished (parental nutrition) there must be high index of suspicion for fungal infections. Therefore we recommend screening for Candida osteomyelistis in these cases. Without treatment, involvement of vertebral bodies can lead to compression fractures, deformity of the spine and neurological impairment

Purpose. To report a retrospective study of 103 cases of primary spinal infection, the largest ever such series from the UK, analysing presenting symptoms, investigations, bacteriology and the results of treatment. Method. This is a retrospective review of all patients (54 Male, 49 Female) treated for primary spinal infection in a Teaching Hospital in the UK. Results. Patients predominantly presented with back pain (78%). Mean time from onset of symptoms to presentation was 72 days. The majority of cases involved patients over 50; however a significant peak also occurred amongst patients in their 20s and 30s. Common co-morbidities in the older age group included diabetes mellitus, renal failure and malignancy whereas the prevailing co-morbidity in the younger group was intra-venous drug abuse. White cell count was infrequently elevated in cases of spondylodiscitis but more commonly so with epidural abscess. The CRP was elevated in most cases at presentation and fell by an average of 62% by the time of discharge. Biopsies were performed in 60% of cases with open biopsy significantly more likely to yield a positive culture than percutaneous techniques. Epidural abscess was the most common diagnosis (42%) with spondylodiscitis, isolated vertebral osteomyelitis and discitis occurring less frequently. The most commonly isolated organism was staphylococcus aureus (51%). Of these, ten cases were infected with Methicillin Resistant Staphylococcus Aureus (MRSA). No organism was isolated in 37% of cases. 28 % of patients were treated with antibiotics alone; the remainder also underwent surgery, most frequently by a posterior approach. Fusion was achieved in 42%. 86% of patients improved symptomatically and 89% cases of paraparesis recovered to some degree after surgical decompression. Conclusion. Our overall impression is of the emergence of a young group of patients with primary spinal infections relating to Intravenous Drug Abuse and of increasing incidence of MRSA as a causative organism

Aim. Cefuroxime is a time-dependent antibiotic widely used as intravenous perioperative prophylaxis in spine surgery. A previous study has indicated that a single dose of cefuroxime provided insufficient spine tissue concentrations for spine procedures lasting more than 2–3 hours. Due to the fact that postoperative pyogenic spondylodiscitis is associated with prolonged antimicrobial therapy and high relapse rates, we aimed to evaluate if a twofold increase of standard dosage of 1.5g cefuroxime given as one double dose or two single doses with 4-hours intervals will lead to sufficient cefuroxime spine tissue concentrations throughout the dosing interval. Method. This is preliminary data for 8 out of 16 female pigs. Data from all 16 pigs will be included for the conference. Eight pigs were randomized into two groups: Group A received one double dose of cefuroxime (3g) as a bolus, and Group B received two single doses of cefuroxime (2×1.5g) with 4-hours intervals. Measurements were obtained from plasma, subcutaneous tissue (SCT), vertebral cancellous bone and the intervertebral disc (IVD) for 8-hours thereafter. Microdialysis was applied for sampling in solid tissues. The cefuroxime concentrations were determined using ultra-high performance liquid chromatography. Results. The time with concentrations above the minimal inhibitory concentration (T>MIC) for the clinical breakpoint MIC for Staphylococcus aureus of 4 μg/ml, was superior in all compartments when administering cefuroxime as two single doses with 4-hours intervals. For the target MIC of 4 μg/ml, the mean T>MIC in all compartments ranged between 53–73% and 85–95% for Group A and B, respectively. For both groups the area under the concentration-curve (AUC) was higher for plasma compared to the remaining compartments, and the lowest AUCs were found in the vertebral cancellous bone and the IVD. There were no differences in AUC between the two groups. Furthermore, the maximal concentrations were lower for both vertebral cancellous bone and IVD compared to both SCT and plasma. When comparing the two groups, higher maximal concentrations were found in all compartments for Group A. Tissue penetration was incomplete and delayed for all compartments and comparable between the two groups. Conclusions. Despite comparable pharmacokinetic results between the two groups, Group B exhibited superior T>MIC in all compartments for the clinical breakpoint MIC for Staphylococcus aureus of 4 μg/ml. As such administration of cefuroxime as two single doses with 4-hours intervals provided sufficient cefuroxime spine tissue concentrations for a minimum of 85% of an 8-hour dosing interval, which may be acceptable for most spine procedures

Aim. Pyogenic spondylodiscitis is associated with prolonged antimicrobial therapy and high relapse rates. Nevertheless, tissue pharmacokinetic studies of relevant antimicrobials in both prophylactic and therapeutic situations are still sparse. Previous approaches based on bone biopsy and discectomy exhibit important methodological limitations. The objective of this study was therefore to assess the concentration of cefuroxime in intervertebral disc (IVD), vertebral body cancellous bone, subcutaneous adipose tissue (SCT) and plasma pharmacokinetics after single dose administration by use of microdialysis (MD) in a large animal model. Method. Ten female pigs were assigned to receive 1,500 mg of cefuroxime intravenously over 15 min. Measurements of cefuroxime were obtained from plasma, SCT, the vertebral cancellous bone and the IVD for 8 hours thereafter. MD was applied for sampling in solid tissues. The cefuroxime concentration in both the MD and plasma samples was determined using ultra-high performance liquid chromatography. Results. For both the IVD and the vertebral cancellous bone, the area under the concentration-curve from zero to the last measured value was significantly lower than that of free plasma. Tissue penetration of cefuroxime was incomplete for the IVD, whereas for vertebral cancellous bone and SCT it was not. Furthermore, the penetration of cefuroxime from plasma to IVD was delayed. Additionally, a noticeable prolonged elimination rate of cefuroxime in the IVD was found. The maximal concentration and the elimination of cefuroxime were reduced in IVD compared to both SCT and vertebral cancellous bone. Due to this delay in elimination of cefuroxime, the time with concentrations above the minimal inhibitory concentration (T>MIC) was significantly higher in IVD than in SCT, vertebral cancellous bone and free plasma for MICs up to 6 μg/ml. Conclusions. MD was successfully applied for serial assessment of the concentration of cefuroxime in the IVD and the vertebral cancellous bone. Penetration of cefuroxime from plasma to IVD was found to be incomplete and delayed, but due to a prolonged elimination, the best results regarding T>MIC was found in IVD

The goal of this work is to evaluate the epidemiology and treatment employed in the treatment of pyogenic spondylodiscitis. Diagnosis was based on clinical and imaging, it does not include cases of postoperative infection and lesions contiguous with decubitus ulcers. The clinical records were used to obtain demography, comorbidities, presenting symptoms, physical examination, laboratorial values, diagnostic procedures, microbiological profile as well as medical and surgical treatment. Statistical analysis was performed using SPSS 20. After reviewing 22 patients met the inclusion criteria. The mean age was 60.82(range 22–86), 82 % were men(n=18). Most prevalent comorbidities were diabetes mellitus 41%(n=9), chronic alcoholism 18% (n=4), CKD 14%(n=3) and HIV in 9%(n=2). Approximately 40.1% had a septic focus in another location, the most common UTI 30%(n=3) and 20% sepsis(n=2). The most common symptoms were LBP 51%(n=21), weight loss 15%(n=6) and fever 12%(n=5). Laboratory evaluation revealed an average leukocytosis 11.8(range 4.3–21.8), ESR averaged 83.9 mm/h (range 10–128), mean CRP 11.6 mg/dl(range 0.4–38.7). The lumbar spine was the most affected segment 55%(n=12), then the dorsal 36%(n=8) and cervical 9%(n=2). The microbiological diagnosis was established in 55% of cases (n=12), 8(66.7%) cases were identified in blood cultures and 3(25%) in bone biopsy. The most common agents identified were MSSA in 18% of cases (n=4) and cogulase negative staphylococci 18%(n=4). A surgical procedure was performed in 86.4% (n=19), 7 for fusion and in 4 a transpedicular biopsy. The indications for surgery were crop material, abscess drainage and instability each with 32%(n=6). In terms of neurological sequelae 23%(n=5) had changes. The average length of stay was 57.4 days(range 19–190), mortality was 9%(n=2). We found no statistically significant differences regarding the identification of microorganisms using age (p=0.644), ESR(p=0.233), CRP(p=0.166) and leukocytosis(p=0.147) as variables. Our series has characteristics common to literature, predominantly male, risk factors as Diabetes, CKD and HIV are common. Alcoholism is linked with some immunosuppression and appears as a new risk factor. Obtaining microbiological diagnosis is crucial to avoid the need for prolonged antibiotic therapy and the potential increased costs and toxicity of broad spectrum. The low number of positive biopsy (25%) is explained by the early empirical antibiotic therapy before sampling. Surgery plays an important role in crop products for microbiological analysis and treatment of instability or neurological deficits. A high index of suspicion in patients with known risk factors and back pain is crucial since delay in diagnosis leads to worse outcomes