Spinal Infections Guidelines

Updated: Feb 28, 2020
  • Author: Federico C Vinas, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
  • Print
Guidelines

IDSA Guidelines for Native Vertebral Osteomyelitis

In 2015, the Infectious Diseases Society of America (IDSA) published clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis (NVO) in adults. [39]  

Recommendations pertaining to diagnosis included the following:

  • NVO is typically diagnosed in the setting of recalcitrant back pain unresponsive to conservative measures and elevated inflammatory markers with or without fever
  • Plain radiographs of the spine are not sensitive for the early diagnosis of NVO
  • Magnetic resonance imaging (MRI) of the spine is often required to establish the diagnosis
  • Except in septic patients or patients with neurologic compromise, empiric antimicrobial therapy should be withheld, when possible, until a microbiologic diagnosis is confirmed
  • An image-guided or intraoperative aspiration or biopsy of a disc space or vertebral endplate sample submitted for microbiologic and pathologic examination often establishes the microbiologic or pathologic diagnosis of NVO
  • NVO is commonly monomicrobial and most frequently due to  Staphylococcus aureus
  • Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and fever
  • Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
  • Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and bloodstream infection or infective endocarditis
  • Clinicians may consider the diagnosis of NVO in patients who present with fever and new neurologic symptoms with or without back pain
  • Clinicians may consider the diagnosis of NVO in patients who present with new localized neck or back pain, following a recent episode of  S aureus bloodstream infection
  • A pertinent medical and motor/sensory neurologic examination is recommended in patients with suspected NVO
  • Obtain bacterial (aerobic and anaerobic) blood cultures (2 sets) and baseline ESR and CRP in all patients with suspected NVO
  • A spine MRI is recommended in patients with suspected NVO
  • A combination spine gallium/technetium-99m bone scan is recommended, or a computed tomography (CT) scan or a positron emission tomography (PET) scan, in patients with suspected NVO when MRI cannot be obtained (eg, implantable cardiac devices, cochlear implants, claustrophobia, or unavailability)
  • Obtain blood cultures and serologic tests for  Brucella species in patients with subacute NVO residing in endemic areas for brucellosis
  • Obtain fungal blood cultures in patients with suspected NVO and at risk for fungal infection (epidemiologic risk or host risk factors)
  • Perform a purified protein derivative (PPD) test or obtain an interferon gamma release assay in patients with subacute NVO and at risk for  Mycobacterium tuberculosis NVO (ie, originating or residing in endemic regions or having risk factors)
  • In patients with suspected NVO, evaluation by an infectious disease specialist and a spine surgeon may be considered
  • An image-guided aspiration biopsy is recommended in patients with suspected NVO (on the basis of clinical, laboratory, and imaging studies) when a microbiologic diagnosis for a known associated organism ( S aureusS lugdunensis, and  Brucella species) has not been established by blood cultures or serologic tests
  • Recommend against performing an image-guided aspiration biopsy in patients with  S aureusS lugdunensis, or  Brucella species bloodstream infection suspected of having NVO on the basis of clinical, laboratory, and imaging studies
  • Advise against performing an image-guided aspiration biopsy in patients with suspected subacute NVO (high endemic setting) and strongly positive  Brucella serology

Treatment recommendations included the following:

  • In patients with neurologic compromise with or without impending sepsis or hemodynamic instability, immediate surgical intervention and initiation of empiric antimicrobial therapy are recommended
  • In patients with normal and stable neurologic examination and stable hemodynamics, hold empiric antimicrobial therapy until a microbiologic diagnosis is established
  • In patients with hemodynamic instability, sepsis, septic shock, or progressive or severe neurologic symptoms, initiate empiric antimicrobial therapy in conjunction with an attempt to establish a microbiologic diagnosis
  • A total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy is recommended for most patients with bacterial NVO
  • A total duration of 3 months of antimicrobial therapy is recommended for most patients with NVO due to  Brucella species
  • Surgical intervention is recommended in patients with progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate antimicrobial therapy
  • Surgical debridement with or without stabilization is recommended in patients with persistent or recurrent bloodstream infection (without alternative source) or worsening pain despite appropriate medical therapy (weak, low)
  • Recommend 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