Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults

Publication Date: July 29, 2015
Last Updated: September 2, 2022

Diagnosis

fever, (S/L)
675
elevated ESR or CRP, (S/L)
675
Concomitant bloodstream infection or infective endocarditis. (S/L)
675
fever and new neurologic symptoms with or without back pain. (W/L)
675
new localized neck or back pain, following a recent episode of S. aureus bloodstream infection. (W/L)
675
IDSA recommends performing a pertinent medical and a motor/sensory neurologic examination in patients with suspected NVO. (S/L)
675
IDSA recommends obtaining bacterial (aerobic and anaerobic) blood cultures (two sets) and baseline ESR and CRP in all patients with suspected NVO. (S/L)
675
IDSA recommends a spine MRI in patients with suspected NVO. (S/L)
675
IDSA suggests a combination spine gallium/Tc99 bone scan, or Computerized Tomography (CT) scan or a Positron Emission Tomography (PET) scan in patients with suspected NVO when MRI cannot be obtained (e.g., implantable cardiac devices, cochlear implants, claustrophobia, or unavailability). (W/L)
675
IDSA recommends obtaining blood cultures and serology tests for Brucella sp. in patients with subacute NVO residing in endemic areas for brucellosis. (S/L)
675
IDSA suggests obtaining fungal blood cultures in patients with suspected NVO and at risk for fungal infection (epidemiologic risk or host risk factors). (W/L)
675
IDSA suggests performing a purified protein derivative (PPD) test or obtaining an interferon gamma release assay in patients with subacute NVO and at risk for Mycobacterium tuberculosis NVO (TB NVO) (i.e., originating or residing in endemic regions or having risk factors). (W/L)
675
In patients with suspected NVO, evaluation by an infectious diseases specialist and a spine surgeon may be considered. (W/L)
675
IDSA recommends an image-guided aspiration biopsy in patients with suspected NVO (based on clinical, laboratory, and imaging studies) when a microbiologic diagnosis for a known associated organism (S. aureus, S. lugdunensis, and Brucella sp.) has not been established by blood cultures or serologic tests. (S/L)
675
IDSA advises against performing an image-guided aspiration biopsy in patients with S. aureus, S. lugdunensis or Brucella sp. bloodstream infection suspected of having NVO based on clinical, laboratory and imaging studies. (S/L)
675
IDSA advises against performing an image-guided aspiration biopsy in patients with suspected subacute NVO (high endemic setting) and strongly positive brucella serology. (S/L)
675
In patients with neurologic compromise with or without impending sepsis or hemodynamic instability, IDSA recommends immediate surgical intervention and initiation of empiric antimicrobial therapy. (S/L)
675
IDSA suggests the addition of fungal, mycobacterial, or brucella cultures on image-guided biopsy and aspiration specimens in patients with suspected NVO if epidemiologic, host risk factors, or characteristic radiologic clues are present. (W/L)
675
IDSA suggests the addition of fungal and mycobacterial cultures, and bacterial nucleic acid amplification test (NAAT) to appropriately stored specimens if aerobic and anaerobic bacterial cultures reveal no growth in patients with suspected NVO. (W/L)
675
If adequate tissue can be safely obtained, pathology specimens should be sent from all patients to help confirm a diagnosis of NVO and guide further diagnostic testing, especially in the setting of negative cultures. (S/L)
675
In the absence of concomitant bloodstream infection, IDSA recommends obtaining a second aspiration biopsy in patients with suspected NVO in whom the original image-guided aspiration biopsy specimen grew a skin contaminant [coagulase-negative staphylococci (except S. lugdunensis), Propionibacterium sp. or diphtheroids]. (S/L)
675
In patients with a non-diagnostic first image-guided aspiration biopsy and suspected NVO, further testing should be done to exclude difficult-to-grow organisms (e.g., anaerobes, fungi, Brucella sp. or mycobacteria). (S/L)
675
In patients with suspected NVO and a non-diagnostic image-guided aspiration biopsy and laboratory work-up, IDSA suggests either repeating a second image-guided aspiration biopsy, a percutaneous endoscopic discectomy and drainage (PEDD), or proceeding with an open excisional biopsy. (W/L)
675

Treatment

Antibiotics

In patients with normal and stable neurologic exam and stable hemodynamics, IDSA suggests holding empiric antimicrobial therapy until a microbiologic diagnosis is established. ( W/L )
675
In patients with hemodynamic instability, sepsis, septic shock, severe or progressive neurologic symptoms, IDSA suggests the initiation of empiric antimicrobial therapy in conjunction with an attempt at establishing a microbiologic diagnosis. ( W/L )
675
IDSA recommends a total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy for most patients with bacterial NVO. ( S/L )
675
IDSA recommends a total duration of 3 months of antimicrobial therapy for most patients with NVO due to Brucella sp. ( S/M )
675

Surgery

IDSA recommends surgical intervention in patients with progressive neurologic deficits, progressive deformity and spinal instability with or without pain despite adequate antimicrobial therapy. ( S/L )
675
IDSA suggests surgical debridement with or without stabilization in patients with persistent or recurrent bloodstream infection (without alternative source) or worsening pain despite appropriate medical therapy. ( W/L )
675
IDSA advises against surgical debridement and/or stabilization in patients who have worsening bony imaging findings at 4-6 weeks in the setting of improvement in clinical symptoms, physical examination, and inflammatory markers. ( W/L )
675

Follow-Up

Systemic Inflammatory Markers and MRI

IDSA suggests monitoring systemic inflammatory markers (ESR and or CRP) in patients with NVO after approximately 4 weeks of antimicrobial therapy, in conjunction with a clinical assessment. ( W/L )
675
IDSA recommends against routinely ordering follow-up MRI in patients with NVO in whom a favorable clinical and laboratory response to antimicrobial therapy was observed. ( S/L )
675
IDSA suggests performing a follow-up MRI to assess evolutionary changes of the epidural and paraspinal soft tissues in patients with NVO who are judged to have a poor clinical response to therapy. ( W/L )
675

Failure of Therapy

IDSA suggests that persistent pain, residual neurologic deficits, elevated markers of systemic inflammation, or radiographic findings alone, do not necessarily signify treatment failure in treated NVO patients. (W/L)
675
In patients with NVO and suspected treatment failure, IDSA suggests obtaining markers of systemic inflammation (ESR and CRP). Unchanged or increasing values after 4 weeks of treatment should increase suspicion for treatment failure. ( W/L )
675
IDSA recommends obtaining a follow-up MRI with emphasis on evolutionary changes in the paraspinal and epidural soft tissue findings in patients with NVO and suspected treatment failure. ( S/L )
675
In patients with NVO and clinical and radiographic evidence of treatment failure, IDSA suggests obtaining additional tissue samples for microbiologic (bacteria, fungal, and mycobacterial) and histopathologic examination, either by image-guided aspiration biopsy or through surgical sampling. ( W/VL )
675
In patients with NVO and clinical and radiographic evidence of treatment failure, IDSA suggests consultation with a spine surgeon and an infectious disease physician. (W/VL)
675

Recommendation Grading

Overview

Title

Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults

Authoring Organization

Infectious Diseases Society of America

Publication Month/Year

July 29, 2015

Last Updated Month/Year

October 9, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Target Patient Population

Adults with Native vertebral osteomyelitis (NVO)

Target Provider Population

Y infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and professionals who care for patients with NVO

PICO Questions

  1. When should the diagnosis of NVO be considered?

  2. What is the appropriate diagnostic evaluation of patients with suspected NVO?

  3. When should an image-guided aspiration biopsy or additional workup be performed in patients with NVO?

  4. How long should antimicrobial therapy be withheld prior to an image-guided diagnostic aspiration biopsy in patients with suspected NVO?

  5. When is it appropriate to send fungal, mycobacterial, or brucellar cultures or other specialized testing following an image-guided aspiration biopsy in patients with suspected NVO?

  6. When is it appropriate to send the specimens for pathologic examination following an image-guided aspiration biopsy in patients with suspected NVO?

  7. What is the preferred next step in patients with nondiagnostic image-guided aspiration biopsy and suspected NVO?

  8. When should empiric antimicrobial therapy be started in patients with NVO?

  9. What is the optimal duration of antimicrobial therapy in patients with NVO?

  10. What are the indications for a surgical intervention in patients with NVO?

  11. How should failure of therapy be defined in treated patients with NVO?

  12. What is the role of systemic inflammatory markers and MRI in the follow-up of treated patients with NVO?

  13. How do you approach a patient with NVO and suspected treatment failure?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D010019 - Osteomyelitis, D015299 - Discitis

Keywords

osteomyelitis, vertebral osteomyelitis, spondylodiscitis, Staphylococcus aureus, spine infection, spine infection, discitis

Source Citation

Elie F. Berbari, Souha S. Kanj, Todd J. Kowalski, Rabih O. Darouiche, Andreas F. Widmer, Steven K. Schmitt, Edward F. Hendershot, Paul D. Holtom, Paul M. Huddleston, III, Gregory W. Petermann, Douglas R. Osmon, 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults, Clinical Infectious Diseases, Volume 61, Issue 6, 15 September 2015, Pages e26–e46, https://doi.org/10.1093/cid/civ482