Large increase of vertebral osteomyelitis in France: a 2010-2019 cross-sectional study.

Vertebral osteomyelitis (VO) represents 4-10% of bone and joint infections. In Western countries, its incidence seems to increase, simultaneously with an increasing number of comorbidities among an ageing population. This study aimed to assess the evolution of VO epidemiology in France over the 2010-2019 decade. A nationwide cross-sectional study was conducted using the French hospital discharge data collected through the French diagnosis-related groups 'Programme de Médicalisation des Systèmes d'Information'. VOs were detected with a previously validated case definition using International Classification of Diseases 10 (ICD-10) codes, implemented with the French current procedural terminology codes. The study population included all patients hospitalised in France during the 2010-2019 decade, aged 15 years old and more. Patient and hospital stay characteristics and their evolutions were described. During the study period, 42 105 patients were hospitalised for VO in France involving 60 878 hospital stays. The mean VO incidence was 7.8/100 000 over the study period, increasing from 6.1/100 000 in 2010 to 11.3/100 000 in 2019. The mean age was 64.8 years old and the sex ratio was 1.56. There were 31 341 (74.4%) patients with at least one comorbidity and 3059 (7.3%) deceased during their hospital stay. Even if rare, device-associated VOs (4450 hospital stays, 7.3%) highly increased over the period. The reliability of the method, based upon an exhaustive database and a validated case definition, provided an effective tool to compare data over time in real-life conditions to regularly update the epidemiology of VO.

Deep Spinal Infection after Outpatient Epidural Injections for Pain: A Retrospective Sample Cohort Study Using a Claims Database in South Korea.

BACKGROUND: Deep spinal infection is a devastating complication after epidural injection. This study aimed to investigate the incidence of deep spinal infection primarily after outpatient single-shot epidural injection for pain. Secondarily, this study assessed the national trends of the procedure and risk factors for said infection. METHODS: Using South Korea's National Health Insurance Service sample cohort database, the 10-yr national trend of single-shot epidural injections for pain and the incidence rate of deep spinal infection after the procedure with its risk factors were determined. New-onset deep spinal infections were defined as those occurring within 90 days of the most recent outpatient single-shot epidural injection for pain, needing hospitalization for at least 1 night, and receiving at least a 4-week course of antibiotics. RESULTS: The number of outpatient single-shot epidural injections per 1,000 persons in pain practice doubled from 40.8 in 2006 to 84.4 in 2015 in South Korea. Among the 501,509 injections performed between 2007 and 2015, 52 cases of deep spinal infections were detected within 90 days postprocedurally (0.01% per injection). In multivariable analysis, age of 65 yr or more (odds ratio, 2.91; 95% CI, 1.62 to 5.5; P = 0.001), living in a rural area (odds ratio, 2.85; 95% CI, 1.57 to 5.0; P < 0.001), complicated diabetes (odds ratio, 3.18; 95% CI, 1.30 to 6.7; P = 0.005), multiple epidural injections (three times or more) within the previous 90 days (odds ratio, 2.34; 95% CI, 1.22 to 4.2; P = 0.007), and recent use of immunosuppressants (odds ratio, 2.90; 95% CI, 1.00 to 6.7; P = 0.025) were significant risk factors of the infection postprocedurally. CONCLUSIONS: The incidence of deep spinal infection after outpatient single-shot epidural injections for pain is very rare within 90 days of the procedure (0.01%). The data identify high-risk patients and procedure characteristics that may inform healthcare provider decision-making.

Microbiological diagnosis of suspected vertebral osteomyelitis with a focus on the yield of percutaneous needle biopsy: a 10-year cohort study.

This study aims to evaluate in patients hospitalized for vertebral osteomyelitis (VO) the effectiveness of bacteriological diagnosis and the yield of percutaneous needle biopsy (PNB) and to identify factors associated with the result of PNB. This retrospective, two-centre study was conducted between 2000 and 2009. Data on patients with VO were retrieved from the diagnosis database and confirmed by checking medical records. A total of 300 patients with VO were identified; 31 received antibiotics without bacteriological diagnosis, and 269 patients with spondylodiscitis imaging were included. Eighty-three (30.9%) and 18 (6.7%) infections were documented by blood cultures and by bacteriological samples other than PNB, respectively; 168 patients with no bacteriological diagnosis had PNB. Of these, 92 (54.8%) were positive and identified the pathogen and 76 (45.2%) were negative. The most common bacteria were Staphylococcus aureus (34.3%), Streptococcus spp. (20.6%) and coagulase-negative staphylococcus (14.8%). After multivariate analysis, the only factor associated with negative PNB was previous antibiotic intake (OR: 2.31 [1.07-5.00]). When VO was suspected on imaging, bacteriological investigation identified the microorganism in 209/300 (70%) of the cases. The yield of PNB was 54.8%. The only predictor of PNB negativity was previous antibiotic intake. Therefore, we believe that a second PNB should be done after a sufficient delay withdrawal of antibiotics if the first sample was negative. The study was retrospectively registered by the local ethics committee (N°E2019-61).

Bartonella osteomyelitis versus vertebral sarcoidosis: A tale of two cases.

BACKGROUND: Osteomyelitis is an uncommon manifestation of Bartonella henselae. Similarly, bony involvement may occur with sarcoidosis. Even though these are pathologically distinct entities, they can have overlapping imaging manifestations and therefore mimic one another. This is further complicated by the fact that both entities show non-caseating granulomatous inflammation on histopathology. We present two cases with similar imaging findings, with one case eventually diagnosed as Bartonella osteomyelitis, while the other proved to be vertebral sarcoidosis. Both patients exhibited vertebral involvement in common, and improved clinically and radiographically following antibiotics and steroids treatment, respectively. Given the overlapping pathological and imaging manifestations, and the non-specific clinical presentation, these entities may be considered in the differential consideration of each other. The presence of associated findings in such cases may be helpful.

Pyogenic psoas abscess on the dorsal side, and bacterial meningitis and spinal epidural abscess on the ventral side, both of which were induced by spontaneous discitis in a patient with diabetes mellitus: A case report.

Type 2 diabetes mellitus patients are immunocompromised, particularly under poorly controlled conditions, and thereby they could develop rare inflammatory diseases, such as spontaneous discitis, pyogenic psoas abscess, spinal epidural abscess and bacterial meningitis. Herein we report a pyogenic psoas abscess on the dorsal side, and bacterial meningitis and spinal epidural abscess on the ventral side, both of which were induced by spontaneous discitis in a patient with poorly controlled type 2 diabetes mellitus. This case was very rare and interesting, because we successfully treated various infections with antibiotics over a long period of time, complicated by hyperglycemic crises, although the patient suffered severe bone destruction and required rehabilitation for a long time.

Candida albicans causing cervical pyomyositis: A case report / Piomiositis cervical por Candida albicans: A propósito de un caso

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Infecciones piógenas de la columna vertebral / Pyogenic spinal infections

Las infecciones espinales son cuadros clínicos poco frecuentes, que exigen un alto índice de sospecha. La prevalencia de infecciones piógenas de la columna ha ido en aumento, en parte debido al envejecimiento de la población y a un mayor número de pacientes inmunocomprometidos. El estudio imagenológico se puede iniciar con radiografías simples, pero la resonancia magnética es el examen imagenológico de elección, ya que puede dar resultados positivos de forma precoz, entregando información más detallada del compromiso vertebral y tejidos blandos adyacentes. Aunque la clínica y los hallazgos imagenológicos nos pueden orientar, es importante intentar un diagnóstico microbiológico tomando cultivos y muestras para identificar al agente causal antes de iniciar los antibióticos; aunque es óptimo un tratamiento agente-específico, hasta un 25% de los casos queda sin diagnóstico del agente. El tratamiento es inicialmente médico, con antibióticos e inmovilización, pero se debe considerar la cirugía en casos de compromiso neurológico, deformidad progresiva, inestabilidad, sepsis no controlada o dolor intratable. El manejo quirúrgico actual consiste en el aseo y estabilización precoz de los segmentos vertebrales comprometidos. Descartar una endocarditis concomitante y el examen neurológico seriado son parte del manejo de estos pacientes.

Spinal infections are unusual conditions requiring a high index of suspicion for clinical diagnosis. There has been a global increase in the number of pyogenic spinal infections due to an aging population and a higher proportion of immunocompromised patients. The imaging study should start with plain radiographs, but magnetic resonance imaging (mri) is the gold standard for diagnosis. Mri can detect bone and disc changes earlier than other methods, and it provides detailed information on bone and adjacent soft tissues. Blood cultures and local samples for culture and pathology should be obtained, trying to identify the pathogen. According to the result, the most appropriate drug must be selected depending on susceptibility and penetration into spinal tissues. Treatment should start with antibiotics and immobilization; surgery should be considered in cases with neurological impairment, progressive deformity, spine instability, sepsis, or non-controlled pain. Current surgical treatment includes debridement and early stabilization. Practitioners should rule out endocarditis and perform a serial neurological examination managing these patients.

Infecção cervicofacial grave de origem odontogênica: relato de caso / Severe cervicofacial infection of odontogenic origin: case report

Introdução: as infecções odontogênicas tem como principal origem a necrose pulpar com invasão bacteriana no tecido periapical e periodontal, podendo levar à formação de quadros de celulite e posteriormente de abscesso, além disso, possuem o potencial de disseminar-se pelos espaços faciais profundos e comprometer a vida do paciente. Complicações graves, decorrentes dos quadros de infecções odontogênicas, podem ocorrer, se o tratamento instituído não for adequado, como: trombose do seio cavernoso, abscesso cerebral, mediastinite e até óbito. Objetivo: discutir o manejo das infecções odontogênicas disseminados em espaços faciais profundos, através do relato de caso clínico. Caso clínico: paciente de 52 anos, portador de diabetes mellitus tipo 2, com infecção odontogênica, no exame clínico inicial apresentava trismo, disfonia, dispneia, disfagia, hiperemia e edema em lado esquerdo da face, envolvendo os espaços canino, bucal, submandibular e cervical além de unidades dentárias com foco infeccioso. Em exame de tomográfica computadorizada, observou-se desvio da via área, presença de um grande volume de gás e de lojas de infecção. Optou-se como tratamento a remoção dos focos dentários e drenagem intraoral foi realizada pela equipe da CTBMF com anestesia local e posteriormente drenagem sob anestesia geral, intubação com uso de fibroscopia pela equipe de cirurgia cabeça e pescoço. Considerações finais: as infecções odontogênicas que envolvem espaços faciais profundos devem ser tratadas com urgência e o tratamento de escolha dessa condição deve ser remoção imediata do foco infeccioso, exploração e drenagem rápida e agressiva dos espaços faciais envolvidos e associação com antimicrobianos de amplo espectro com características bactericidas.(AU)

Introduction: the main origin of odontogenic infections is pulp necrosis with bacterial invasion in the periapical and periodontal tissue, which may lead to the formation of cellulitis and later abscess, besides having the potential to spread to the deep facial spaces and compromise the patient's life. Severe complications from dental infections may occur if the treatment is not appropriate, such as cavernous sinus thrombosis, brain abscess, mediastinitis and even death. Objective: to discuss the management of disseminated odontogenic infections in deep facial spaces through a case report. Case report: a 52-year-old patient with type 2 diabetes mellitus, with odontogenic infection, presented at the initial clinical examination trismus, dysphonia, dysphagia, dysphagia, hyperemia and edema on the left side of the face involving the canine, buccal, submandibular and cervical spaces. of dental units with infectious focus. CT scan revealed deviation of the airway, presence of a large volume of gas and infection stores. The treatment was chosen to remove dental foci and intraoral drainage was performed by the CTBMF team under local anesthesia and subsequently under general anesthesia drainage, intubation with fibroscopy by the head and neck surgery team. Final considerations: odontogenic infections involving deep facial spaces should be treated urgently and the treatment of choice for this condition should be immediate removal of the infectious focus, rapid and aggressive exploration and drainage of the involved facial spaces and association with broad-spectrum antimicrobials with bactericidal characteristics.(AU)

Predictive factors for positive disco-vertebral biopsy culture in pyogenic vertebral osteomyelitis, and impact of fluoroscopic versus scanographic guidance.

BACKGROUND: The aims of this study were to identify the predictive factors for microbiological diagnosis through disco-vertebral biopsy (DVB) in patients with pyogenic vertebral osteomyelitis (PVO) and negative blood cultures, and compare the performance of DVB under fluoroscopic versus scanographic guidance. METHODS: We performed a cohort study comparing positive and negative DVB among patients with PVO. All cases of PVO undergoing a DVB for microbiological diagnosis in our center were retrospectively reviewed. Infections due to Mycobacterium tuberculosis, infections on foreign device, and non-septic diseases were excluded. Anamnestic, clinical, biological, microbiological, as well as radiological data were collected from medical charts thanks to a standardized data set. RESULTS: A total of 111 patients were screened; 88 patients were included. Microbiological cultures were positive in 53/88 (60.2%) patients. A thickening of the paravertebral tissue ≥10 mm on magnetic resonance imaging (MRI) in axial MR scans was a predictive factor of DVB microbiological positivity (52.4% vs. 13.3%; p = 0.006; OR = 5.4). Overall, 51 DVB were performed under fluoroscopic guidance and 37 under scanographic guidance. Considering lumbar DVB, 25/36 (69.4%) of cases yielded positive results under fluoroscopic guidance versus 5/15 (33.3%) under scanographic guidance (p = 0.02; OR = 4.4). No adverse event linked to DVB was notified. CONCLUSION: Every patient with PVO and negative blood cultures should undergo a DVB. A thickening of the paravertebral tissue ≥10 mm on MRI is associated with a higher rate of positive DVB culture. A lumbar DVB under fluoroscopic guidance is more sensitive than under scanographic guidance to identify the micro-organism involved.

How is the microbial diagnosis of bacterial vertebral osteomyelitis performed? An 11-year retrospective study.

Vertebral osteomyelitis (VOM) is often diagnosed with delays, resulting in poorer outcomes. Microbial documentation is particularly challenging and obtained using blood cultures (BCs) and vertebral biopsies (VBs; CT-guided or surgical). We retrospectively analysed VOM cases in a tertiary reference centre between 2004 and 2015, focusing on how and how quickly microbiological diagnosis was performed. Among 220 VOM, 88.2% had documentation, including Gram-positive cocci (GPC) (70.6%), Gram-negative rods (GNR) (9.3%), anaerobes (3.6%), polybacterial infections (6.7%) and tuberculosis (9.8%). BCs were performed in 98.2% and positive in 59.3%, identifying most GPC (80.3%) and half of GNR (54.6%). VBs were performed in fewer cases (37.7%), but were more frequently positive (68.8% for CT-guided and 81.0% for surgical biopsies). They documented all anaerobes (100.0%), most M. tuberculosis (84.2%) and polybacterial infections (76.9%), and GNR (45.4%). Extra-vertebral samples highly contributed to tuberculosis diagnosis (52.6%, and 15.8% as the only positive sample). Documentations most often followed radiological diagnosis (53.4%). They were obtained earlier by BCs than by VB after first clinical symptoms (median of 14 versus 51 days). Antibiotic treatments were mostly initiated after samplings (88.0%). BCs allow the documentation of most VOM and should be performed without delay in case of clinical or radiological suspicion; however, they may miss 1 out of 5 GPC and 1 out of 2 GNR. VBs have a higher positivity rate and should be rapidly performed if negative BCs. It is likely that delayed and missed diagnoses result from the insufficient use of VB.

Different kinetics of infectious processes in vertebral osteomyelitis of pyogenic or tuberculous origin explain different timing of surgery.

Background: Whether surgery modalities vary according to kinetics of pathological processes responsible for vertebral osteomyelitis (VO) is unclear. We therefore compared surgical modalities in patients with haematogenous pyogenic VO (HPVO) or tuberculous VO (TVO).Methods: Patients who had surgery for HPVO or TVO between January 1997 and June 2018 in a university hospital were included. Surgical indications, timing, and procedures and outcomes were evaluated at the end of treatment.Results: Seventy-eight patients (50 men) were included: 39 with HPVO and 39 with TVO; median age was 64 and 41 years, respectively. In patients with HPVO, surgery was performed early: 17 (44%) had surgery within 72 h of admission; main indication for surgery was neurological deficit in 29 patients that persisted in 12 patients (27%). In patients with TVO, surgery was performed later (p<.001), after two weeks in 20 patients (51%), and was indicated by a neurological deficit in 23 patients; among them, only one (4%) had residual deficit.Conclusions: Different kinetic profiles of the infectious processes explain the more rapid indication for surgery in patients with HPVO and the more favourable neurological recovery in patients with TVO.

MRI and clinical features of acute fungal discitis/osteomyelitis.

OBJECTIVES: To compare imaging and clinical features of fungal and Staphylococcus aureus discitis-osteomyelitis (DO) for patients presenting for CT-guided biopsies. METHODS: Our study was IRB-approved and HIPAA-compliant. A group of 11 fungal DO (FG) with MRI within 7 days of the biopsy and a control group (CG) of 19 Staphylococcus aureus DO were evaluated. Imaging findings (focal vs diffuse paravertebral soft tissue abnormality, partial vs complete involvement of the disc/endplate), biopsy location, pathology, duration of back pain, immune status, history of intravenous drug, history of prior infection, current antibiotic treatment, and history of invasive intervention. Differences were assessed using the Fisher exact test and Kruskal-Wallis test. Naïve Bayes predictive modeling was performed. RESULTS: The most common fungal organisms were Candida species (9/11, 82%). The FG was more likely to have focal soft tissue abnormality (p = 0.040) and partial disc/endplate involvement (p = 0.053). The clinical predictors for fungal DO, in order of importance, back pain for 10 or more weeks, current antibiotic use for 1 week or more, and current intravenous drug use. History of invasive instrumentation within 1 year was more predictive of Staphylococcus aureus DO. CONCLUSION: MRI features (focal partial soft tissue abnormality and partial involvement of the disc/endplate) in combination with clinical features may help to predict fungal species as a causative organism for DO. KEY POINTS: • MRI features of discitis-osteomyelitis (focal partial soft tissue abnormality and partial involvement of the disc/endplate) in combination with clinical features may help to predict fungal species as a causative organism for DO.

[Vertebral cryptococosis. Case report and literature review]. / Criptococosis vertebral. Comunicación de un caso y revisión bibliográfica.

Cryptococcosis is an infectious disease caused by a ubiquitous encapsulated yeast called Cryptococcus neoformans, it is usually associated with immunosuppressed patients. Osteomyelitis occurs in 5-10%, the spine involvement is one of the most reported. The purpose of this work is to present a case of isolated vertebral cryptococcosis and detail the results of a literature review. The treatment protocol is not yet established but it is recommended to start with aggressive intravenous therapy and continue with a suppressive treatment orally during a variable time. Surgical indication is considered in lesions that affect the spinal stability, deformity or neurological compromise and for local infectious control.

Mycobacteriumabscessus-associated vertebral osteomyelitis in an immunocompetent patient: a rare case report and literature review.

Introduction: Vertebral osteomyelitis (VO) is an uncommon infection with Staphylococcus aureus as the most commonly implicated organism. VO caused by nontuberculous mycobacteria (NTM) such as Mycobacteriumabscessus (M. abscesscus) is exceedingly rare with only eight cases reported in literature. Case presentation: We report a rare case of an 82-year-old male with a remote history of trauma who was diagnosed with NTM vertebral osteomyelitis. The patient initially underwent a vertebroplasty of T12 and kyphoplasty of L1 for pathologic compression fractures. Subsequent cultures revealed M. abscessus. The patient further underwent an anterior T12-L2 corpectomy and debridement with instrumented fusion, as well as a posterior T9-L4 instrumentation and fusion. He received multi-agent antibiotic therapy; however, was ultimately unable to tolerate the aggressive treatment regimen and his prolonged postoperative course. Discussion: Nontuberculous mycobacteria vertebral osteomyelitis is exceedingly rare. NTM vertebral osteomyelitis is challenging to treat. Surgical management plays a limited role in early VO, but is the mainstay treatment in chronic VO. Early recognition of the condition and shared patient management with multidisciplinary teams is key to successfully treating cases of NTM VO.

Criptococosis vertebral: comunicación de un caso y revisión bibliográfica / Vertebral cryptococosis: case report and literature review

Resumen La criptococosis es una micosis sistémica producida por un hongo levaduriforme encapsulado denominado Cryptococcus neoformans. Es una enfermedad universal, que ocurre con mayor frecuencia en pacientes inmunocomprometidos, manifestándose principalmente como una enfermedad diseminada con compromiso meníngeo o pulmonar. Sin embargo, la osteomielitis ocurre solo en 5-10% de los casos, siendo el compromiso vertebral el más frecuente. Presentamos un caso de criptococosis vertebral aislada y una búsqueda bibliográfica sobre el tema. Se recomienda realizar una terapia antifúngica de inducción intravenosa y continuar con una fase de consolidación, vía oral, de duración variable. La indicación quirúrgica se considera en lesiones que comprometen la estabilidad vertebral y aquellas que presentan un compromiso neurológico, producen deformidad y para reducir el inóculo infeccioso.

Cryptococcosis is an infectious disease caused by a ubiquitous encapsulated yeast called Cryptococcus neoformans, it is usually associated with immunosuppressed patients. Osteomyelitis occurs in 5-10%, the spine involvement is one of the most reported. The purpose of this work is to present a case of isolated vertebral cryptococcosis and detail the results of a literature review. The treatment protocol is not yet established but it is recommended to start with aggressive intravenous therapy and continue with a suppressive treatment orally during a variable time. Surgical indication is considered in lesions that affect the spinal stability, deformity or neurological compromise and for local infectious control.

Successful medical drainage and surgical treatment for vertebral osteomyelitis and bilateral psoas abscess with gas formation caused by klebsiella pneumoniae in a diabetic patient.

OBJECTIVE: We describe the case of a diabetic patient who developed vertebral osteomyelitis and bilateral psoas abscess with gas formation due to klebsiella pneumoniae. METHODS: A 64-year-old woman with a 4-year history of type-2 diabetes mellitus was admitted to the Emergency Department. The subject had a 2-day history of high-grade fever associated with chills and a 5-hour history of consciousness. She received empirical treatment with febrifuge, after which her fever decreased. RESULTS: Her fever recurred after an interval of three hours. A computed tomography scan of the abdomen revealed vertebral osteomyelitis and bilateral psoas muscle abscess with gas formation. Blood culture and purulent fluid described the growth of the Klebsiella pneumoniae. The patient received antibiotic therapy and bilateral drainage therapy after the drainage catheter was placed into the abscess cavity by CT-guidance. Due to the serious damage to the vertebral column and permanent pain, the patient underwent minimally invasive internal spinal fixation and recovered successfully. CONCLUSION: A case of vertebral osteomyelitis and bilateral psoas abscess with gas formation caused by Klebsiella pneumoniae in a diabetic patient. Antibiotic therapy, drainage, and minimally invasive internal spinal fixation were performed, which enabled a good outcome.

Spinal blastomycosis: unusual musculoskeletal presentation with literature review.

We report a case of a 41-year-old male who presented to our institution with a large groin mass. CT, MRI and PET imaging was performed and was concerning for a soft tissue abscess likely originating in the lumbar spine. Differential considerations included infection, with atypical infections such as tuberculosis strongly considered. Biopsy revealed fungal elements preliminarily reported as consistent with Cryptococcus neoformans but later revealed to be Blastomyces dermatitidis. The patient responded positively following the introduction of appropriate treatment. This case illustrates the imaging similarities between spinal blastomycosis, spinal tuberculosis, and other fungal infections as well as the need for biopsy to differentiate.