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

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.

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.

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.

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.

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.

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.

Aim. Spondylodiscitis and vertebral osteomyelitis can lead to long-term sequelae if not diagnosed and treated promptly and appropriately. The Royal National Orthopaedic Hospital (RNOH) has devised a new spinal infection referral system within the UK that allows cases to be discussed in a specialist multi-disciplinary (MDT) forum. National guidelines were devised in 2013 to help guide treatment, which recommends both tissue biopsies from the affected region and a MRI of the entire spine. The aims of this study were to assess the current treatment and referral practices and compare them with the set guidelines. It is hypothesised that a high percentage of patients are started on antibiotics without a biopsy or a positive set of blood cultures, a low percentage of patients are referred without undergoing a MRI of the full spine and that there is a long delay in referral to the MDT. Method. A retrospective case study analysis was carried out on all spinal infection referrals received by the Royal National Orthopaedic Hospital over a 2-year period (2014–16), using the standards set by the current national guidelines. Clinical features, haematology results, imaging, biopsy results, treatment and outcome were all reviewed. Three key areas were addressed; whether antibiotics were commenced before positive cultures or biopsy, whether a MRI of the entire spine was performed and the time taken for referral from the onset of symptoms. Results. A total of 49 cases were identified, the average age was 56 years and the majority were male (67%). The most common organisms grown were staphylococcus aureus and mycobacterium tuberculosis. Lumbar (37%) and thoracic (31%) spine were the most predominant regions affected. As predicted only 42% of the patients were referred with a whole spine MRI, only 33% had a biopsy and 29% had positive blood cultures before starting antibiotics. The average time to referral was 62 days overall (10 days for acute referrals). Conclusions. This multicentre study highlights a number of key concerns with both the referral and treatment of spinal infections. New national infection guidelines recommend a tissue sample prior to antibiotics; however this study showed that only 45% of patients had either a biopsy or positive blood culture before starting antibiotics. The time to referral was prolonged and the majority of patients did not receive a whole spine MRI. Overall this confirms the study's hypothesis and the need for better management of this complex and debilitating condition

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