Three-Month Antibiotic Therapy for Early-Onset Postoperative Spinal Implant Infections

Dubée, Vincent; Lenoir, T.; Leflon‐Guibout, Véronique; Briere-Bellier, Claire; Guigui, P.; Fantin, Bruno

doi:10.1093/cid/cis769

Cited by 45 publications

(28 citation statements)

References 18 publications

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“…We used the following standard definitions (7,8). Noncontiguous vertebral osteomyelitis was defined as clinical signs and symptoms, radiography, and laboratory information consistent with vertebral osteomyelitis, without evidence of skin disruption over spine (from surgery or ulcers) (all were presumably hematogenous in origin).…”

Section: Data Collectionmentioning

confidence: 99%

Factors Associated with Treatment Failure in Vertebral Osteomyelitis Requiring Spinal Instrumentation

Arnold

Rock

Croft

et al. 2014

Antimicrob Agents Chemother

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There are no randomized, controlled trials to guide decisions about specific antimicrobial regimens or duration of therapy for vertebral osteomyelitis (1). Pathogen-directed parenteral antimicrobial therapy is curative in the majority of cases (2-4). However, some patients have complications, such as abscess formation or loss of neurological function, that require significant surgical intervention. Surgical intervention involves debridement, sometimes accompanied by instrumentation in order to stabilize the spine (5). Instrumentation with placement of prosthetic material such as rods, screws, or plates into an infected area poses an additional challenge for the infectious disease specialist, who must determine an antimicrobial treatment course. The optimal duration of antimicrobial therapy and the need for posttreatment suppressive therapy following instrumentation of vertebral osteomyelitis remain unknown (6). Approaches to treatment vary from indefinite antimicrobial therapy in an attempt to suppress a presumed infection of foreign material to immediate cessation of antimicrobials after completion of parenteral therapy (6).The aim of our study was to examine risk factors for treatment failure in a cohort of patients requiring spinal instrumentation in the setting of acute noncontiguous vertebral osteomyelitis. MATERIALS AND METHODSStudy setting. The University of Maryland Medical Center (UMMC) is a 648-bed urban tertiary care hospital in Baltimore, MD. It serves as a center for orthopedic surgery. The Institutional Review Board (IRB) at the University of Maryland School of Medicine approved this study.Study design. We constructed a retrospective cohort of all cases of vertebral osteomyelitis of noncontiguous origin that required spinal instrumentation to stabilize the spine between 1 January 2002 and 31 January 2012 at UMMC. Cases were excluded if they had Ͻ4 weeks of postoperative follow-up. No cases had spinal instrumentation prior to surgery for osteomyelitis, and no patients had osteomyelitis from a surgical site infection. Data collection.We utilized the UMMC Medical Informatics database to identify all discharges with at least one ICD-9-CM code for osteomyelitis of the spine or unspecified site (codes 730.28, 730.08, 730.2, and 730.00); spondylodiscitis, disc infection, displacement, or disorder (722, 722.0, 722.1, 722.2, and 722.7); epidural abscess (324.1 and 324.9); or discitis (722.90, 722.91, 722.92, and 722.93) and at least one ICD-9-CM procedure code for spinal fusion or refusion (81.0, 81.00, 81.02, 81.03, 81.04, 81.05, 81.06, 81.07, 81.08, 81.3, 81.31, 81.32, 91.33, 81.34, 81.35, 81.36, 81.37, 81.38, and 81.39); operation, incision and excision, or grafting of vertebrae or intervertebral disc (78.09, 80.09, 80.51, 80.99, and 77.70); and exploration and decompression of spinal canal structures, removal of foreign body from spinal canal, or insertion of interbody spinal fusion device (84.51, 03.0, and 03.09).Patient records containing these ICD-9-CM codes were then reviewed manually to determi...

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Section: Data Collectionmentioning

confidence: 99%

Factors Associated with Treatment Failure in Vertebral Osteomyelitis Requiring Spinal Instrumentation

Arnold

Rock

Croft

et al. 2014

Antimicrob Agents Chemother

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“…Relapse after treatment is infrequent, but difficult to diagnose [4][5][6]. McHenry et al [7] showed that, during a 6.5-year follow up, 14% of the patients relapsed, most of them during the first 12 months after treatment withdrawal.…”

Section: Introductionmentioning

confidence: 99%

Interest of [ 18 F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of relapse in patients with spinal infection: a prospective study

Dauchy¹,

Dutertre

Lawson-Ayayi

et al. 2016

Clinical Microbiology and Infection

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Relapse after treatment of a spinal infection is infrequent and difficult to diagnose. The aim of this study was to assess the diagnostic performance of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in this setting. Thirty patients (21 men, nine women; median age 61.2 years) with a suspected spinal infection relapse were prospectively included between March 2010 and June 2013. The initial diagnosis of spinal infection was confirmed by positive bacterial cultures. The patients underwent [(18)F]FDG PET/CT and magnetic resonance imaging (MRI) 1 month after antibiotic treatment interruption. PET/CT data were interpreted both visually and semi-quantitatively (SUVmax). The patients were followed for ≥12 months and the final diagnosis of relapse was based on new microbiological cultures. Seven patients relapsed during follow up. Sensitivity, specificity, positive predictive value and negative predictive value were 66.6%, 61.9%, 33.3% and 86.6%, respectively for MRI and 85.7, 82.6, 60.0 and 95.0 for PET/CT. Although these values were higher for PET/CT than for MRI, the difference was not statistically significant (p=0.3). [(18)F]FDG PET/CT may be useful for diagnosing a relapse of spinal infections, in particular if metallic implants limit the performance of MRI.

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“…1,23 There is a discussion about the efficacy of the closed irrigation system, the need for removing instrumentation and primary or secondary wound closure. [3][4][5]12,[14][15][16][17][18][24][25][26][27][28][29][30] In our experience, these patients can be successfully managed with aggressive surgical debridement combined with a closed irrigation system and primary wound closure without removing the instrumentation.…”

Section: Discussionmentioning

confidence: 84%

“…10,13 No consensus exists in the literature regarding primary or delayed wound closure, the need or not for a suction-irrigation system and the need to remove the instrumentation. 4,5,[14][15][16][17][18] The purpose of this surgical prospective cohort study was to investigate the efficacy in patients with DWI after instrumented posterior lumbar spinal surgery for degenerative diseases through a protocol with wound exploration, washing, extensive debridement, use of closed irrigation system for five days, appropriate antibiotic therapy and maintaining the instrumentation, as well as to what extent blood tests can predict the need for reintervention.…”

Section: Introductionmentioning

confidence: 99%

Management of wound infection after lumbar arthrodesis maintaining the instrumentation

et al. 2015

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<sec><title>OBJECTIVE:</title> To determinate whether a surgical protocol with immediate extensive debridement, closed irrigation system and antibiotic therapy would be effective to achieve healing of deep wound infection without removing the instrumentation.</sec><sec><title>METHODS:</title> Prospective cohort study with 19 patients presenting degenerative spinal stenosis or degenerative spondylolisthesis, who developed infection after posterior lumbar arthrodesis. The diagnosis was confirmed by a microbial culture from subfascial lumbar fluid and/or blood. Patients were treated with a protocol of wound exploration, extensive flushing and debridement, placement of a closed irrigation system that was maintained for five days and intravenous antibiotics. The instrumentation system was not removed.</sec><sec><title>RESULTS:</title> Mean age was 59.31 (±13.17) years old and most patients were female (94.7%; 18/19). The mean period for the identification of the infection was 2 weeks and 57.9% underwent a single wound exploration. White blood count, erythrocyte sedimentation rate and C-reactive protein showed a significant decrease post-treatment when compared to pre-treatment values. A significant reduction of erythrocyte sedimentation rate and C-reactive protein was also observed at the final evaluation. No laboratory test was useful to predict the need for more than one debridement.</sec><sec><title>CONCLUSION:</title> Patients with wound infection after instrumentation can be treated without removal of the instrumentation through wound exploration, extensive flushing, debridement of necrotic tissue, closed irrigation system during 5 days and proper antibiotic therapy. The blood tests were not useful to predict surgical re-interventions.</sec>

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Three-Month Antibiotic Therapy for Early-Onset Postoperative Spinal Implant Infections

Abstract: In this homogenous cohort of 50 patients with EOSII, treatment consisting of debridement surgery with implant retention followed by combination antibiotic therapy for 3 months appeared safe and effective.

Cited by 45 publications

References 18 publications

Factors Associated with Treatment Failure in Vertebral Osteomyelitis Requiring Spinal Instrumentation

Factors Associated with Treatment Failure in Vertebral Osteomyelitis Requiring Spinal Instrumentation

Interest of [ 18 F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of relapse in patients with spinal infection: a prospective study

Management of wound infection after lumbar arthrodesis maintaining the instrumentation

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