Introduction. Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections. Materials & methods. Sheffield Spinal Infection Database collects data prospectively from regularly held Spinal infection MDTs. We accrued 125 spinal infections between September 2008 and October 2010. The medical records, blood results, radiology and bacteriology results of all patients identified were reviewed. In patients with negative first biopsy, second biopsy is contemplated and parenteral broad spectrum antibiotic treatment initiated. Results. There were 81 pyogenic, 16 tuberculous and 28 postoperative spinal infections. The mean age was 58.4 years (range, 19 to 88 years). There were 71 male and 54 female patients. There were 64 lumbar and 26 thoracic infections. Two level and multi-level spinal infections involving more than two segments occurred in 30 patients. Of sixty positive microbiology yields, the most common organism was methicillin sensitive staphylococcus aureus (n-23) followed by Streptococcal, E Coli and Coagulase negative staphylococcal and Pseudomonas infections. Second biopsy (done when first biopsy negative) was only positive in two patients. Conclusions. Annual incidence of de novo spinal infection was 48 (pyogenic-40, tuberculous-8). The most frequently isolated pathogen was Staphyloccus aureus. Multi-level infection, diabetic patients, resistant TB and postop infection in elderly patients constituted the ‘difficult to treat’ group in our experience. An algorithm for the diagnostic work-up and management of spinal infections is proposed

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

Background. There is minimal published data regarding the long-term functional outcome in pyogenic spinal infection. Previous studies have used heterogeneous, unreliable and non-validated measure instruments, or neurological outcome alone, yielding data that is difficult to interpret. We aim to assess long-term adverse outcome using standardised measures, Oswestry disability index (ODI) and MOS short form-36 (SF-36). Methods. All cases of pyogenic spinal infection presenting to a single institution managed operatively and non-operatively from 1994-2004 were retrospectively identified. Follow-up was by clinical review and standardised questionnaires. Inclusion in each case was on the basis of consistent clinical, imaging and microbiology criteria. Results. Twenty-nine cases of pyogenic spinal infection were identified. Twenty-eight percent were managed operatively and 72% with antibiotic therapy alone. Nineteen patients (66%) had an adverse outcome at a median follow-up of 61 months, despite only 5 patients (17%) having persistent neurological deficit. A significant difference in SF-36 PF (physical function) scores was observed between patients with adverse outcome and patients who recovered (p=0.003). SF-36 scores of all patients, regardless of management or outcome, failed to reach those of a normative population. A strong correlation was observed between ODI and SF-36 PF scores (rho=0.61, p<0.05). Seventeen percent (n=5) of admissions resulted in acute sepsis-related death. Subgroup analysis revealed delay in diagnosis of spinal infection (p=0.025) and neurological impairment at diagnosis (p<0.001) to be significant predictors of neurological deficit at follow-up. Previous spinal surgery was associated with adverse outcome in patients requiring readmission within 1 year of hospital discharge following first spinal infection (p=0.018). No independent predictors of adverse outcome, persistent neurological impairment, readmission within 1 year or acute death were identified by logistical regression analysis. Conclusions. High rates of adverse outcome detected using SF-36 and ODI suggest under-reporting of poor outcome when ASIA score alone is used to qualify outcome

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

Objective. Pyogenic spinal infection (PSI) is an increasingly common presentation to spinal units in the UK. Its investigation and diagnosis is often delayed. The purpose of this study was to determine the prognostic significance of the inflammatory marker levels on admission on achieving a positive microbiological diagnosis in patients with PSI. Study design. Retrospective case series review of all patients presenting with PSI to our unit. Subjects. Clinical data were collected on 96 consecutive patients diagnosed with a PSI over a 7-year period. Patient < 18 years at time of presentation or who had previous spinal surgery were excluded. Outcome Measures. Positive blood and/or tissue culture, and requirement for surgery. Continuous data were compared using the Wilcoxon rank-sum test∗∗ and logistical regression remodelling was assessed using the Spearman correlation∗. Categorical data was analysed using Fisher's exact test. ∗∗∗. Results. The C-reactive protein was statistically significant for; duration of preceding symptoms (p=0.0003)∗, isolation of a causative organism (p< 0.0001)∗∗, positive biopsy culture (p=0.0016)∗∗ and requirement for surgery (p=0.031)∗∗. The White Blood Cell (WBC) count was statistically significant for; duration of preceding symptoms (p< 0.0001)∗, isolation of a causative organism (p = 0.0003)∗∗, positive biopsy culture (p=0.0023)∗∗. The majority of patients who had a positive tissue culture had a positive blood culture (p< 0.0001)∗∗∗. Conclusion. The inflammatory marker levels on admission are a useful prognostic marker for isolating a causative organism in patients with PSI and help guide treating surgeons to whether proceeding to biopsy is likely to be a helpful investigation. Tissue biopsy in patients with PSI is only marginally superior to blood culture alone

Aims

Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford.

Aim. Cutibacterium acnes is a significant cause of late-onset spinal implant infection (SII). In addition, usual preoperative prophylactic measures may be insufficient to prevent C. acnes operating site colonisation and infection, as demonstrated for prosthetic shoulder surgery. However, little information is available regarding risk factors for SII due to this microorganism. The aims of this study were to determine the characteristics of and risk factors for C. acnes SII. Method. we conducted a retrospective unmatched case-control study including all adult patients treated for mono and polymicrobial C. acnes SII during 2010–2015. Controls were randomly selected among patients diagnosed with SII due to other microorganisms during the same period. Results. Fifty-nine patients with C. acnes SII were compared with 59 controls. There was no difference in sex distribution (39% vs 53% men). Patients with C. acnes SII were younger (median age 42 vs. 65, p< 0.001), thinner (median body mass index (BMI) 21 vs. 25 kg/m. 2. , p< 0.001), and presented a better health status (ASA score≤ 2, 83% vs. 65%, p= 0.015; and presence of immunosuppression, 3% vs. 27%, p= 0.002). Patients with C. acnes SII were more likely to experience delayed/late infections (i.e. diagnosed >3 months post-instrumentation, 66% vs. 22%, p< 0.001) and to be instrumented for scoliosis (83% vs. 27%, p< 0.001) with an extended osteosynthesis (median number of fused vertebrae 12 vs. 5, p< 0.001). However, 20 C. acnes SII (34%) developed early (≤3 months) after instrumentation. The clinical presentation was significantly more indolent in the C. acnes group (presence of fever, 27% vs. 61%, p= 0.001; wound inflammation 39% vs. 61%, p< 0.001 and median C-reactive protein level 38 vs. 146 mg/L). Mixed C. acnes SII were diagnosed on 24 occasions (41%), 22 of which involving both C. acnes and staphylococcal strains. In the multivariate logistic regression model, factors independently associated with the development of SII involving C. acnes were age less than 65 (adjusted odds ratio [aOR] 7.13, 95% CI [2.44–24.4], p= 0.001), BMI< 22kg/m. 2. (aOR 3.71 [1.34–10.7], p= 0.012) and a number of fused vertebrae >10 (aOR 3.90 IC 95% [1.51–10.4], p= 0.005). Conclusions. There were significant differences between SII involving C. acnes and those involving other microorganisms. We identified a specific profile of patients at increased risk of developing C. acnes SII. These findings could contribute to improve both the prevention and treatment of such infections

Aim. Spinal infections with and without aSCI represent a severe disease with a high lethality rate of up to 17%. The current treatment recommendations include an antimicrobial therapy and if necessary in combination with operative procedures. Aims of this study are the analysis of risk factors and treatment concepts and to compare the outcome of patients suffering a spinal infection with and without an aSCI. Method. Monocentric prospective case study from 2013 – 2015. Patients were examined using a diagnostic algorithm (CT-thorax/abdomen, MRI total-spine, blood cultures, dental chart, echocardiogram). A calculated antimicrobial therapy was initially administered and later changed according to the antibiotic resistance. Additional operative procedures were performed with respect to the clinical and radiological findings. Results. 68 patients (age 69.8 ± 13.7 years) were included. A Charlson-Comorbidity-Index of 3.9 ± 2.5 was calculated. An spinal infection with aSCI was associated with a significantly higher number of infected spinal segments (p=0.013). A longer duration of antibiotic treatment (statistically non-significant) and a higher operation rate was shown with aSCI. Also the inpatient and intensive-care unit treatment duration was significantly longer with aSCI. The number of treatment-associated complications and the lethality were equal in both groups. The age (odds-ratio 1.1 per one year increase; p=0.02) and the appearance of an epidural empyema (odds-ratio 7.9; p=0.04) have been identified as independent lethality factors. Conclusions. Patients with spinal infections are multimorbid and have multiple infectious origins, which warrant further diagnostic investigations. Treatment associated complications, lethality rates and clinical outcome of spinal infection with and without aSCI are comparable in a specialized unit. Lethality risk factors are age and presence of an epidural empyema. In subsequent studies the antibiotic treatment duration and the long-term follow up will be evaluated

Aim. In severe cases of postoperative spinal implant infections (PSII) multiple revision surgeries may be needed. Little is known if changes of the microbiological spectrum and antibiotic resistance pattern occur between revision surgeries. Therefore, the aim of this study was to analyze the microbiological spectrum and antibiotic resistance pattern in patients with multiple revision surgeries for the treatment of PSII. Furthermore, changes of the microbiological spectrum, distribution of mono vs. polymicrobial infections, and changes of the antimicrobial resistance profile in persistent microorganisms were evaluated. Method. A retrospective analysis of a prospectively maintained single center spine infection database was performed with a minimum follow-up of 3 years. Between 01/2011 and 12/2018, 103 patients underwent 248 revision surgeries for the treatment of PSII. Overall, 20 patients (6 male/14 female) underwent 82 revisions for PSII (median 3; range 2–12). There were 55/82 (67.1%) procedures with a positive microbiological result. Microbiological analysis was performed on tissue and implant sonication fluid. Changes in microbial spectrum and antibiotic resistance pattern between surgeries were evaluated using Chi-Square and Fisher's exact test. Results. In total, 74 microorganisms (83.3% gram-positive; 10.8% gram-negative) were identified. The most common microorganisms were Staphylococcus epidermidis (18.9%) and Cutibacterium acnes (18.9%). All S. epidermidis identified were methicillin-resistant (MRSE). Overall, there were 15/55 (27.3%) polymicrobial infections. The microbiological spectrum changed in 57.1% (20/35) between the revision stages over the entire PSII period. In 42.9% (15/35) the microorganism persisted between the revision surgeries stages. Overall, changes of the antibiotic resistance pattern were seen in 17.4% (8/46) of the detected microorganisms comparing index revision and all subsequent re-revisions. Moreover, higher resistance rates were found for moxifloxacin and for ciprofloxacin at first re-revision surgery compared with index PSII revision. Resistances against vancomycin increased from 4.5% (1/23) at index PSII revision to 7.7% (2/26) at first re-revision surgery. Conclusions. Changes of the microbiological spectrum and the resistance pattern can occur in patients with severe PSII who require multiple revision surgeries. It is important to consider these findings in the antimicrobial treatment of PSII. The microbiological analysis of intraoperative tissue samples should be performed at every revision procedure for PSI

Aim. We report our ten year experience of primary haematogenous non-tuberculous spinal infection. Method. Retrospective case note review of 42 patients presented to our institution with primary spinal infection during 1995-2005 was carried out. Demographic data, timing and modes of presentation, investigations, and methods of treatment were analysed. The cost benefit of Home Intravenous Antibiotics Service (HIAS) was also investigated. Results. Mean age was 59.9 years (1-85) with almost equal gender distribution (M 20: F 22). Axial pain was universal. Pyrexia was seen in 62% and major neurological deficit in 10% of cases. Time from presentation to diagnosis averaged 19 days (range 0-172). Sensitivity for MRI and plain x-ray was 100% and 46% respectively. Blood culture was as sensitive as percutaneous biopsy in patients with pyrexia. Staphylococcus Aureus was the most common organism. Treatment ranged from intravenous antibiotics alone to combined anterior and posterior surgery depending on the presence or absence of significant abscess collection, neurological deficit and structural threat. Mean duration of intravenous antibiotics was 54 days (range 13-240). At mean follow up of 5.4 years (0.6-10.5) there was no mortality directly related to the infection. Recurrence rate was 14%. Significant past medical history (p=0.001), constitutional symptoms (p=0.001) and pyrexia at presentation (p=0.001) and possible male gender (p=0.01) were positively associated with recurrence. Although firm conclusions can not be drawn due to sample size, duration of symptoms (p=0.27) did not appear to affect the risk of recurrence. When inpatient days were subtracted from days on IV antibiotics for all the patients, HIAS was found to have saved a total of 940 inpatient days. Conclusion. In spinal infection, disease and patient characteristics dictate the management strategy. Longer antibiotic therapy in patients with positive risk factors for recurrence may be indicated. Finally, HIAS was cost effective in this group of patients

Aim. Spinal infection is the most frequent complication of spine surgery. Its incidence varies between 1% and 14% in the literature, depending on various studied populations and surgical procedures. The aim of this study was to describe a consecutive 2706 case series. Method. We analyzed a prospective cohort of 2706 patients operated for spine disease between 2013 and 2016 in a University Hospital. The infection rates, germs, time between surgery and infection and outcomes after surgical revision were assessed with a minimum follow-up of 7 months. We developed a mathematical model to analyze risk factors in this difficult-to-treat population. Results. Among 2706 patient who underwent spinal surgery during the three-year study period, 106 developed a postoperative spine infection. Clinical indicators for infection were the sudden onset of local pain and swelling without fever after an initial pain-free interval. We observed a masculine predominance (68%); the median age was 56 years. The rate of infection was comprised between 0,3% (discal herniation surgery) to over 20% in posterior cervical instrumented surgery (acute cervical fractures), with a global rate of 4%. Polymicrobial infections with more than 3 germs were found in only 2 case, with 3 germs in 8 cases, 2 germs in 27 cases and 1 germ in 69 cases. Staphylococcus aureus, Propionibacterium acnes and Staphylococcus epidermidis were the three main germs identified (53, 36 and 22 respectively). Propionibacterium acnes was involved with a higher rate in instrumented surgery but also in 8% of conventional non-instrumented surgery, with a median relapse time of 24 days (12 days to 4 years). Staphylococcus aureus was involved at a higher rate in posterior non-instrumented surgery with a median relapse time of 18 days (8–66 days). The rate of infection per month was globally stable along the year except an increased rate in February-March. All patients with a suspicion of post-op infection were initially treated with wound/deep tissues revision within the first month after surgery and associated with implant removal after one-month post-op. Pejorative outcomes were associated with incomplete revision surgery, several surgeries and polymicrobial infection. Conclusions. In this study, the rate of postoperative infection is comparable to the literature. In contrast, Propionibacterium incidence is high, especially for acute infections. This unexpected rate can be linked to technical improvements in culture detection but this should also lead us to further discuss the natural process of spine/disk colonization of this germ

Introduction:. Skeletal TB has a paucibacillary nature. It is often found in poorly accessible areas for biopsy purposes. Retrieved samples may have a poor representation of the underlying disease process. Additionally, patients have normally commenced anti-tubercular medication that further decreases the number of bacilli. This has resulted in poor sensitivity and specificity outcomes for the tests that are traditionally done. The polymerase chain reaction (PCR) has been proven to be a useful test for the demonstration of extrapulmonary TB. It has a high specificity and sensitivity. Objective:. The study measures the sensitivity and specificity of PCR done on fresh biopsies from patients suspected of a tuberculous spinal infection. Method and Results:. A retrospective review of results was done of spinal tissue biopsies. A total of 30 consecutive patients were identified. There were 15 males (mean age = 40,3 yrs) and 15 females (mean age = 45,8 yrs). 18 of the patients were HIV positive. Acid fast bacilli were demonstrated in 4 (13,33%) patients by staining. Culture was positive in 10 (33,33%), in which 2 had commenced antitubercular therapy. Histology reported features in keeping with tuberculosis in 9 (30%) patients. Furthermore, multiple myeloma, adenocarcinoma, osteomyelitis and thyroid carcinoma was reported. PCR was positive in 12 (40%) patients. Sensitivity of PCR was calculated as 85,7% whilst specificity was 72,7% (the amount correctly classified was 77,8%). Only 4 patients had positive tests for all 4 methods used for diagnosing tuberculosis. Conclusion:. Tuberculosis should always be considered in spinal lesions. PCR provides a quick and effective means of identifying it. This allows early commencement of anti-tubercular treatment

Aim. Spinal implant-associated infections (SIAI) require combined surgical and antimicrobial treatment and prolonged hospital stay. We evaluated the clinical, laboratory, microbiological and radiological characteristics and treatment approaches in patients with SIAI. Method. Consecutive adult patients with SIAI treated between 2015 and 2017 were prosepctively included. SIAI was defined by: (i) significant microbial growth from intraoperative tissue or sonication fluid, (ii) intraoperative purulence, secondary wound dehiscence or implant on view, (iii) radiographic evidence of infection and fever (>38°C) without other recognized cause, increasing back pain or neurologic impairment, (iv) peri-implant tissue inflammation in histopathology. Results. A total of 60 patients were included, median age was 66 years (range, 28–91 years), 29 (48%) were males. The most common reason for spinal stabilization was spinal canal stenosis in 20 patients (33%) followed by vertebral degenerative disease in 14 (23%). 31 patients (52%) had one or more previous spine surgeries (range, 1–4 interventions). The anatomic site of spinal instrumentation was lumbar/sacral in 26 (43%), cervical in 23 patients (38%), thoracic in 11 (18%). The median number of fused segments was 5 (range, 1–14). Clinical manifestations included wound healing disturbance in 41 patients (68%), increasing back pain in 15 (25%), neurologic impairment in 12 patients (20%) and fever in 14 (23%). Serum CRP was abnormal (>10mg/l) in 46/59 patients (78%). Most (n=54) infections were postsurgical, 5 were hematogenous and 1 was contiguous. Imaging showed epidural, intraspinal or paravertebral abscess in 21/42 patients (50%), implant failure in 9 (21%) and implant loosening in 3 cases (7%). Monomicrobial infection was observed in 41 (68%), polymicrobial in 16 (27%) patients and culture-negative infection in 3 episodes (5%). Predominant causative pathogens were S. aureus (n=19), coagulase-negative staphylococci (n=18) and gram-negative rods (n=16). Surgery was performed in all patients including debridement and implant retention in 39 patients (65%), partial implant exchange in 10 (17%) and complete exchange in 11 (18%). Antimicrobial treatment included biofilm-active substances in 52 patients (87%). The median duration of antimicrobial therapy was 11,7 weeks (range, 6–12 weeks). 14 patients (23%) recieved suppressive therapy for a median duration of 9 months (range 3–12 months). Conclusions. Most SIAI were seen in lumbar/sacral segments and wound healing disturbance and increasing back pain were the most common manifestations. In 95% the causative pathogen was isolated, predominantly staphylococci. In half of the episodes, abscesses were present. All patients underwent surgery and biofilm-active antibiotics were administered in 87%

Aims

The aim of this paper was to present the clinical features of patients with musculoskeletal sources of methicillin-sensitive Staphylococcus aureus (MSSA) septicaemia.

Aims

Tuberculosis (TB) infection of bones and joints accounts for 6.7% of TB cases in England, and is associated with significant morbidity and disability. Public Health England reports that patients with TB experience delays in diagnosis and treatment. Our aims were to determine the demographics, presentation and investigation of patients with a TB infection of bones and joints, to help doctors assessing potential cases and to identify avoidable delays.