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Background Context: Delayed-onset surgical site infections following spinal instrumentation are uncommon and often present with chronic pain and implant failure. Anaerobic organisms are rarely implicated and identified with difficulty in these infections., Purpose: We report a case of vertebral osteomyelitis and epidural abscess due to Parvimonas micra, an anaerobic bacterium, six months following spinal instrumentation., Study Design/setting: Case Report., Results: P. micra was identified from multiple intraoperative tissue and hardware specimens. With hardware explant and antibiotic therapy, the patient had a successful outcome., Conclusions: To our knowledge, this is the first report of a P. micra hardware-associated spinal infection., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The clinical presentation of spondylsodiscitis/spondylitis are manifold. This commonly leads to a period of several months from initial symptoms to final diagnosis. A standardised treatment is difficult. The purpose of this study is to investigate the treatment carried out for patients with spondylodiscitis or spondylitis to develop an individualised standard care for better treatment., Patients and Methods: Data of 90 patients were retrospective analysed. In particular documented data of the initial examination and the following treatments concerning identification of causes and systematically control of pathogens were examined., Results: In 91 % of patients a diagnostically conclusive MRI was conducted. The degree of spondylidiscitis/spondylitis was mainly ASA criteria I or II (86 %). In 96 % of patients different diagnostic methods for identification of pathogens were conducted and documented. RESULTS confirmed the most common pathogens mentioned in the literature. 75 % of patients were treated by surgery. In 93 % of patients an antibiotic treatment was documented. 50 patients (81 %) were successfully healed., Conclusion: It is important to identify and treat spondylodiscitis/spondylitis as early as possible. Diagnosis by means of blood culture and MRI and treatment of the infection with antibiotics and possibly surgical interventions seem be very suitable, but need to be individualised to each and every patient., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Spondylodiscitis refers to the infection of the intervertebral disc and osteomyelitis of the adjacent endplates, and it is uncommon in the developed world. Broad consensus indicates its incidence is on the rise., Methods: The aim of this retrospective study was twofold. First, we sought to give an up-to-date incidence estimate by comparing case presentation over two time periods (1995-1999 and 2008-2011). Data from the England and Wales census in 2001 and 2011 were used for incidence estimation. The second part of this study aimed to generate management guidance from data from medical and radiographic records of the 2008-2011 patient cohort., Results: The incidence of adult spontaneous spondylodiscitis in the local region between 2008 and 2011 was 3.67/100,000 per year, representing a 150% increase from the incidence in 1995-1999. Our data demonstrate that methicillin sensitive Staphylococcus aureus remains the most common offending pathogen of spontaneous spondylodiscitis. The mean C-reactive protein (CRP) level remained at >30mg/l after a month of starting antibiotic treatment in both medically and surgically managed groups., Conclusions: Evidence suggests that the incidence of spondylodiscitis is on the rise. A review of our case series has demonstrated the effectiveness of intravenous antibiotic therapy. While no official guidance exists for when to switch from intravenous to oral antibiotics, our study shows that CRP at 1 month is >30mg/l and we recommend 6 weeks of intravenous therapy, followed by 6 further weeks of oral therapy.

Parvimonas micra is a rare isolate in clinical specimens. We report a case of spondylodiscitis caused by P. micra, a rarely reported Gram positive cocci. The case was an elderly patient with joint surgery and ischaemic heart disease history. Infection resolved after adequate antibiotic therapy., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Bacteremia due to Streptococcus bovis (now S. gallolyticus) has been traditionally associated to colon or hepatobiliar disease and endocarditis but there is no information on this matter in Chile., Aims: To describe clinical features of adult patients suffering bacteremia by S. bovis/S. gallolyticus, identify the source of the bacteremia and the frequency of endocarditis., Methods: Retrospective-descriptive study using laboratory records., Results: Between January 2003 and August 2014, 23 S. bovis/S. gallolyticus bacteremic events were identified among 22 patients. Mean age was 72.7 years (range 46-96). Co-morbidities were frequent (9.1 to 47.6%). The primary source of bacteremia was intestinal in 52.2%; hepatobiliar in 17.4% and in 34.8% it was not elucidated. Six patients had infective endocarditis (26.1%) and one patient had espondylodiscitis (4.3%). S. bovis represented 39.1% of isolates (all until 2008), S. gallolyticus subsp pasteurianus 39.1% and, S. gallolyticus subsp infantarius and S. gallolyticus subsp gallolyticus 8.7% each one, respectively. Association studies between the bacteremic source or endocarditis with specific S. gallolyticus subspecies were limited by the small number of isolates. Seven patients (30.4%) underwent surgical interventions. In-hospital mortality reached 21.7% (n=5)., Conclusions: Although infrequent, bacteremic events by S. gallolyticus/S. bovis have increased in-hospital mortality, require surgical intervention and affect older patients with co-morbidities. Near two-thirds suffer from colonic or hepatobiliary disease that act as the primary source of bacteremia. In addition, near one fourth is affected by infective endocarditis. Detection of S. gallolyticus/S. bovis in blood cultures prompts a thorough clinical evaluation in order to clarify the source of the bloodstream infection and the presence of complications.

We report a case of spondylodiscitis concurrent with infectious aortic aneurysm caused by Candida tropicalis in a 79-year-old immunocompromised man. The patient underwent percutaneous drainage of the abscess and endoluminal exclusion of the aneurysm using a bifurcated stent graft. Micafungin was administered intravenously for 8 weeks, followed by a prolonged course of oral fluconazole. At the one-year follow-up, no recurrence was noted, and the patient could walk with a cane without low back pain.

Spondylodiscitis is often iatrogenic in nature. We report the case of a 69-year-old man presenting with spondylodiscitis and associated epidural abscess following transrectal ultrasonography guided prostate biopsy despite ciprofloxacin cover. To our knowledge, this is the first case of spondylodiscitis secondary to fluoroquinolone resistant Escherichia coli.

Back pain and spine tenderness over the involved spine segment are common clinical findings of a number of relative benign conditions. However, back pain may be the presenting symptom of vertebral metastases in patients with systemic cancer, including hepatocellular carcinoma, a not uncommon complication in HCV-HIV infected patients. We describe a case of a 51-year-old intravenous drug user with HIV and HCV co-infection who developed dorsal spondylodiscitis due to Pseudomonas aeruginosa, which improved following antibiotic therapy. Three months after the end of therapy, the patient referred recurrence of back pain. The MRI showed different vertebral lesions of the dorsal spine and costal arch which turned out to be hepatocellular carcinoma metastasis at the histological examination. The patient had never been treated with the interferon-ribavirine combination therapy because of a major depressive syndrome. Interferon-free regimens are urgently required for HIV-HCV coinfected patients, especially when interferon-based regimens are contraindicated.

Pyogenic spondylitis and discitis are usually seen following a recent infection or surgery. A septic embolus causes an infarcted area within the bone. Pyogenic spondylitis is characterized by edema, vascular leakage, and supportive inflammatory reaction characterized with polymorphonuclear leukocytes. In tuberculosis of the spine, active lesions are characterized by formation of epithelioid granulomas with central caseating necrosis. Mycobacterium tuberculosis can be shown by histochemical stains for acid-fast bacteria or by immunochemistry. In brucella spondylitis, microgranulomatous proliferation composed of histiocytes containing numerous bacilli without caseating necrosis is characteristic. Brucella melitensis can be shown on histochemical Gram stain., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Spondylodiscitis is defined as an infection of the intervertebral disc and the adjacent vertebral bodies. It represents, at the most, 2-4% of osteoarticular infections in children and its clinical presentation is often insidious. The specific condition of the young child (isolated discitis) is explained by some anatomical peculiarities. We report two cases of spondylodiscitis in children of different ages and review the pediatric characteristics, the role of imaging, the bacteriological diagnosis and the management of this disease.

Introduction: Patients undergoing chronic hemodialysis using tunneled cuffed catheters (TCCs) are at increased risk of metastatic infections, namely endocarditis and spondydodiscitis, and mortality is high in this group. The aim of this study was to determine the clinical features, causative organisms, its susceptibility and outcomes in patients hospitalized with these infections from a single center., Methods: All consecutive patients with TCC and endocarditis and/or spondylodiscitis treated at the authors' institution between 2005 and 2011 were selected retrospectively., Results: A total of 7 cases of endocarditis and 7 cases of spondylodiscitis were diagnosed. Concurrent infection was present in 1 patient. The mean age was 63.4 years, 53.8% were male, 23% had diabetes and 31% had previous immunosuppression. The average time on hemodialysis was 24 months. Those patients with endocarditis presented with fever, and 43% had previous valvular disease; mitral valve involvement was the most common. Early surgery was performed in 2 patients.Concerning spondylodiscitis, the median time from first symptom to diagnosis was 48 days. The first manifestation was back pain in 86% percent of patients, and 71% had an epidural or paraspinous abscess demonstrated by neuroimaging. One patient underwent surgical drainage of the abscess. Regarding both infections, staphylococcus aureus was the most common causative agent with a lower rate of negative blood cultures. All patients received intravenous antibiotics for a mean duration of six weeks. The mortality rate was 46%., Conclusions: A high index of suspicion is critical in the early recognition and management of both of these infections.

Purpose: To determine the safety and efficacy of using a single posterior approach with transforaminal lumbar interbody debridement and fusion (TLIDF) plus pedicle screws fixation in treating infective spondylodiscitis in the lumbar spine., Methods: Between January 2009 and June 2011, 28 patients with infective spondylodiscitis who underwent TLIDF, using autogenous graft and posterior pedicle screws instrumentation, met the indications for surgery, and completed more than 18 months of follow-up, were included. Clinical outcomes were assessed using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and Kirkaldy-Willis functional outcome criteria. Infection status was evaluated using C-reactive protein levels, erythrocyte sedimentation rate, and clinical symptoms. The interbody fusion status and sagittal alignment of the infected segments were assessed using radiographic studies., Results: Intra-operative culture rate was 82.1 %. The most common pathogen was methicillin-resistant Staphylococcus aureus. One post-operative deep wound infection with septic implant loosening and one instance of early aseptic implant loosening were noted. Implants in both patients were subsequently removed. Two infections recurred within 3 months post-operatively, with both subsiding within 3 months after extended antibiotic treatment. VAS and ODI values were significantly improved. The interbody fusion rate was 82.1 % and the lordotic angle of the infected segments and the lumbar spine were corrected by 9.7° and 14.3°, respectively at the last follow-up., Conclusions: A single posterior approach with TLIDF and pedicle screws instrumentation for lumbar infective spondylodiscitis provided a satisfactory clinical outcome, adequate infection control and good fusion rate, and this strategy avoids the risks of anterior or staging surgeries.

Background: Spondylitis in the upper cervical spine can have an insidious onset, with symptoms mimicking low-grade infections or common musculoskeletal disorders. Some patients have neurological symptoms, and if untreated, the outcome may be fatal., Case Presentation: A woman in her fifties had general malaise, weight loss and neck pain over 6-8 weeks. Her sedimentation rate was elevated, and she developed bulbar symptoms. Biopsy and culture samples were harvested endoscopically from the prevertebral area in the C1-C2 region, and confirmed our preliminary diagnosis of localised infection. She was treated with high-dose antibiotics and rigid collar immobilisation until stability of the cervical spine was ascertained., Interpretation: It is difficult to make a differential diagnosis between spondylitis, rheumatoid inflammation and malignancy in the upper cervical spine. Adequate histologic and bacterial culture samples must if possible be obtained from the prevertebral area. This is best achieved transnasally or transorally, under endoscopic and radiological guidance. The neck must be stabilised and patients must have long-term antibiotic treatment followed by permanent neck fixation if indicated.

Background: The incidence of childhood bone and joint infections (BJIs) is not well known, but is useful for identifying epidemiological differences and improving practice., Objective: To determine the incidence of BJI in previously well children and describe their clinical, laboratory and radiological characteristics., Design: A multicentre, population-based, prospective study performed from July 2008 through June 2009., Setting: Region of northern France with a population of 872 516 children <16 years old., Patients: All previously well children admitted in the region with septic arthritis, acute osteomyelitis or spondylodiscitis, diagnosed according to consensus criteria and after blinded radiological review., Main Outcome Measures: The corrected incidence of BJI, determined with a capture-recapture method that used this prospective database and the discharge summary database., Results: 58 cases were identified (median age: 3.6 years, range: 1 month-15.8 years; male to female ratio: 1.6). The completeness of the prospective database was 90%. The corrected incidence of any BJI was 7.1/100 000 children (95% CI 5.3 to 8.9). Thirty patients had septic arthritis (52%, incidence: 3.7/100 000; 95% CI 2.4 to 4.9), 24 osteomyelitis (41%, incidence 3.0/100 000; 95% CI 1.8 to 4.1), 4 spondylodiscitis (7%) and 0 osteoarthritis. Micro-organisms were identified from 15 patients (26%), with Staphylococcus aureus the most frequent organism. Radiological findings were characteristic of infection in 44% of BJI., Conclusions: The corrected incidence of BJI in northern France, according to consensus diagnostic criteria, was 7.1/100 000 children <16 years of age., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Acid-fast bacillus (AFB) spinal osteomyelitis in a patient with AIDS is often presumed to be caused by reactivated Mycobacterium tuberculosis. However, other AFB pathogens can mimic M. tuberculosis and, to ensure appropriate and adequate therapy, should be considered by clinicians. We present a case of aggressive spinal osteomyelitis caused by Mycobacterium heckeshornense in an AIDS patient; a review of the literature is also included., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Purpose: To prospectively compare (18)F-FDG PET/CT and MRI in the diagnosis of haematogenous spondylodiscitis, Methods: The study included 26 patients (12 women, 14 men; mean age 59 ± 17 years) with clinical symptoms of infection of the spine. Patients who had had prior spinal surgery or any type of antibiotic therapy in the previous 3 months were excluded from the study. Whole-body PET/CT 60 min after injection of 4.07 MBq/kg of (18)F-FDG and an MRI scan of the spine was performed in all patients. SUVmax in an area surrounding the lesions with the suspicion of infection as well as a background SUVmean in a preserved area of the spine were calculated for quantification. Infection was diagnosed by microbiological documentation in cultures of image-guided spinal puncture fluid or blood. Infection was excluded if symptoms were absent without antimicrobial therapy during a follow-up of at least 6 months., Results: Spondylodiscitis was confirmed in 18 of the 26 patients. Staphylococcus aureus was found in 8 patients, Mycobacterium tuberculosis in 4, Escherichia coli in 2 and other pathogens in 4. Of the remaining 8 patients, the diagnoses were degenerative spondyloarthropathy in 5 and vertebral fracture in 3. The sensitivity, specificity, and positive and negative predictive value were 83%, 88%, 94% and 70% for (18)F-FDG PET/CT, and 94%, 38%, 77% and 75% for MRI, respectively. The accuracies of (18)F-FDG PET/CT and MRI were similar (84% and 81%, respectively). The combination of (18)F-FDG PET/CT and MRI detected the infection in 100% of the patients with spondylodiscitis. (18)F-FDG uptake, quantified in terms of SUVmax corrected by the background SUVmean, was significantly higher in patients with spondylodiscitis than in those without infection (p < 0.001)., Conclusion: Due to its high specificity, (18)F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. Quantification of uptake in terms of SUVmax was able to discriminate infection of the spine from other processes in this series of patients.

We present a case of a young woman experiencing high thoracic backpain and neurological symptoms of medullar compression due to spondylodiscitis from Mycobacterium tuberculosis. An important differential diagnosis of spondylodiscitis is metastatic lesions of the spine. Metastatic lesions most often appear in the thoracic region of the spine and high thoracic pain should be considered a "red flag". Both conditions often show up late on conventional imaging and we discuss the need for the primary sector to be able to refer directly to magnetic resonance imaging for quick and reliable diagnosis.

We report the case of a 65-year-old man with type 2 diabetes mellitus and α-thalassaemia trait. Investigations for relapsing and remitting fever found vertebral osteomyelitis, discitis and epidural and psoas abscess secondary to Salmonella enterica., (2015 BMJ Publishing Group Ltd.)

We herein describe the first reported case of pyogenic spondylitis and diskitis caused by Helicobacter cinaedi. The results of magnetic resonance imaging and the histology of biopsied tissue were suggestive of acute infection at the lumbar spine. The pathogen was obtained by a blood culture examination and identified by 16S rRNA analysis. Eight weeks of antibiotics therapy resulted in a good clinical course. H. cinaedi infections have been increasingly reported in recent years, but the pathogen's epidemiological and pathological characteristics are still unclear. One of the difficulties in understanding the pathogenesis of H. cinaedi has been the challenges in cultivating the pathogen. Novel strategies for the diagnosis of H. cinaedi must be developed.

Objective: To report multiple cases and investigate etiology of initially single fungal spondylodiscitis that progressively spread to adjacent segments following lumbar discectomy, resulting in multiple spinal involvements., Methods: From January 2005 to May 2013, ten adult patients were admitted or referred to our institution with postoperative discitis. Fungal infections were confirmed by microbiologic and pathologic examinations. The clinical appearance, radiographic features, and treatments of this pathology were investigated., Results: All the patients were previously healthy. The average interval between the occurrence of symptoms and primary lumbar discectomy was 61 days (range, 15-120 days). All the patients were treated with anterior surgical debridement, interbody fusion, and prolonged antifungal therapy. Three patients additionally received combined posterior instrumented fusion. Despite aggressive surgical debridement and antifungal therapy, spread of the infections to adjacent multiple discs was observed. No deaths, severe neurologic deficits, or deterioration of neurologic status were noted. The infections were completely resolved in all cases with spontaneous fusion within an average follow-up of 32.4 months., Conclusion: Fungal spondylodiscitis after surgery represents an intractable and troublesome complication, and surgical debridement may not impede the progression of the infection in cases where an insufficient course of antifungal treatment is administered. Such cases may require prolonged antifungal treatment with regular consultation by an infectious disease specialist., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background Context: Although the incidence of pyogenic spinal infections is increasing, the ideal treatment of spondylodiscitis is still a controversially discussed issue. Furthermore, the proportion of multiresistant bacteria in spondylodiscitis is increasing, and treatment recommendations or reported results are missing for this especially difficult subset of patients., Purpose: The aim of this study is to evaluate the surgical outcome and the postoperative antibacterial treatment regime., Study Design: Retrospective case series., Patient Sample: Patients treated for a spondylodiscitis from multiresistant bacteria at our department between 2006 and 2011., Methods: Data were gathered through review of patients' case notes, relevant imaging, and electronic records. Magnetic resonance imaging of the whole spine including gadolinium (Gd)-enhanced T1 sequences and computed tomography scans of the affected regions were obtained in all cases., Outcome Measures: C-reactive protein (CRP) and complete blood cell count were analyzed in all cases using routine laboratory techniques. Neurologic deficits were classified according to the American Spinal Injury Association (ASIA) impairment scale., Results: Twenty-five patients were identified (15 gram-positive and 10 gram-negative drug-multiresistant bacteria). The mean age at presentation was 66 years, and 14 patients were male (56%). All patients presented with pain, and a neurologic deficit was present in 11 (44%) cases. An epidural abscess was found in 11 (44%) cases. At admission, CRP was elevated in all cases with a mean of 13±9.2 mg/dL. The main source of infection was previous spine surgery (36%). All patients in this series underwent surgical debridement of the infection and instrumentation of the spine. Postoperative intravenous antibiotics were administered for 19±8.6 days followed by 3±0.3 months of oral antibiotic therapy. Eradication of the infection was achieved ultimately in all surviving patients. Out of 11 patients with neurologic deficits, 4 had a full recovery, 4 improved incompletely, and 3 remained unchanged after surgery., Conclusions: Staged surgical immobilization and instrumentation and optimal debridement at the interdiscal space and spinal canal is a reliable approach to achieve complete healing of spinal infection with multiresistant bacteria. A period of intravenous antibiotic therapy of 2 to 3 weeks followed by a 3-month oral antibiotic therapy seems appropriate for most cases., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Despite significant advances in the conservative management of pyogenic spondylodiscitis, consecutive instability, deformity, and/or neurologic compromise demands a prompt surgical intervention. However, in rare cases involving additional multilevel epidural abscess formation, the appropriate surgical strategy remains controversial. In this retrospective cohort analyses, we evaluated the efficacy of a single-stage posterior approach with the addition of a one-time multilevel epidural lavage via the surgically exposed interlaminar fenestration of the infected segment., Methods: From January 2009 through December 2010, 73 patients presenting pyogenic spondylodiscitis with instability of the lumbar spine were admitted. In all cases, the surgical strategy included a radical resection of the affected intervertebral disc and stabilization by intervertebral fusion using a titanium cage with autologous bone grafting in a level-dependent posterior approach with additional pedicle screw-and-rod instrumentation. In cases where multilevel abscess formation was evident, the standard surgical procedure was complemented by drainage and irrigation of the abscess from posterior by carefully advancing a soft infant feeding tube via the surgically exposed epidural space under fluoroscopic guidance. All patients received complementary oral antibiotic therapy for 12 weeks and were followed-up for a minimum of 12 months postoperatively., Results: Ten patients (three male and seven female patients; mean age: 64.9 ± 10.9 years) presented with an additional lumbar epidural abscess extending beyond three levels proximal or distal to the infected disc. In all 10 patients the laboratory-chemical inflammatory parameters (leukocyte count, C-reactive protein) remained within the physiologic range after completing antibiotic therapy throughout the 1-year follow-up period. The plain radiographs and magnetic resonance imaging demonstrated solid fusion and the complete remission of the initial abscess formation after 3 to 6 months with no recurrence of infection, respectively., Conclusion: The onetime epidural lavage presented in this small patient cohort proved to be an effective surgical adjunct with minimal exposure-related morbidity. We believe that the possibility of early mobilization and the patient's increased rehabilitation potential reduce the risk of nosocomial complications that often coincide with this multimorbid high-risk group of patients., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Spondylodiscitis (SD) is an uncommon but important infection. The aim of this work was to study the risk factors, bacteriological features, clinical, laboratory and radiological findings of SD, and to shed light on the initial treatment., Methodology: A total of 107 patients who underwent treatment for SD were evaluated. The diagnosis of SD was defined by clinical findings, complete blood count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), serum tube agglutination (STA) test, Ziehl-Neelsen staining, culture, histopathology, and radiological methods such as magnetic resonance imaging (MRI) and computed tomography (CT) scans., Results: Of the 107 cases, ranging between 17 to 83 years of age, 64 (59.8%) were male. Twenty-seven (25.2%) patients had diabetes mellitus. Laboratory investigations revealed elevated CRP in 70 (65%) patients, elevated ESR in 65 (61%) patients, and elevated white blood cell (WBC) counts in 41 (38.3%) patients. Thirty-six (33.6%) patients were identified as having brucellar SD, and 5 (4.7%) patients were identified as having tuberculous SD. A total of 66 (61.6%) patients were determined to have pyogenic SD. The most frequently isolated microorganism was Staphylococcus aureus. Antibiotic therapy was given intravenously to all pyogenic SD patients., Conclusions: The incidence of SD has increased as a result of the higher life expectancy of older patients with chronic debilitating diseases and the increase of spinal surgical procedures. In patients with low back pain, SD should be considered as a diagnosis. For effective treatment, it is important to determine the etiology of the disease.

We report here a rare case of chronic lumbar discitis caused by Clostridium perfringens in an elderly patient that was treated with a combination of β-lactams and clindamycin. Molecular analysis performed on the strain revealed an unusual toxin gene pattern., (Copyright © 2014, American Society for Microbiology. All Rights Reserved.)

We report a successfully treated case of spondylodiscitis and bloodstream infection due to vancomycin heteroresistant Staphylococcus capitis, in an adult immunocompetent patient with multiple antibiotics intolerance. S. capitis is rarely involved in osteomyelitis and, to our knowledge, this is the first report of vancomycin heteroresistance phenomenon in an S. capitis strain causing spondylodiscitis., (Copyright © 2014 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Spinal infections represent a group of rare conditions affecting vertebral bodies, intervertebral discs, paraspinal soft tissues, epidural space, meninges, and spinal cord. The causal factors, clinical presentations, and imaging features are a challenge because the difficulty to differentiate them from other conditions, such as degenerative and inflammatory disorders and spinal neoplasm. They require early recognition because delay diagnosis, imaging, and intervention may have devastating consequences especially in children and the elderly. This article reviews the most common spinal infections, their pathophysiologic, clinical manifestation, and their imaging findings.

Mycobacterium kansasii is an acid-fast bacillus most commonly associated with pulmonary pathology. Infection of the spine is exceedingly rare, with just three reported cases, two of which were in human immunodeficiency virus and acquired immunodeficiency syndrome patients. This case report presents a case of vertebral osteomyelitis secondary to M. kansasii infection and reviews existing literature on this pathogen. The patient, a 37-year-old male with sarcoidosis, sustained a M. kansasii infection of the spine, resulting in vertebral osteomyelitis of L1 and L2 and discitis of the L1-L2 disc. This finding was confirmed by bone and intervertebral disc biopsy. Initially, the patient was thought to have a compression fracture of L2. However, the decision to perform a biopsy was made because of the patient's persistent febrile episodes and magnetic resonance imaging findings. The patient did not have any neurological deficits. He was successfully treated with antimicrobials, with no recurrent symptoms at 2-year follow-up. This case is the first reported case of a M. kansasii infection of the spine in a patient with sarcoidosis.

Study Design: Retrospective clinical case series., Objective: To report on the epidemiological, microbiological, and clinical characteristics of spinal infections in patients who have undergone solid organ transplantation., Summary of Background Data: Spine infections remain a therapeutic challenge, particularly in patients who are immunocompromised. Solid organ transplant patients represent a growing population of immunocompromised hosts. To our knowledge, no previous reports have examined the clinical characteristics spinal infections in this at-risk population in a systematic fashion., Methods: The records of patients with a history of solid organ transplantation from January 2007 through December 2012 were identified using Current Procedural Terminology procedure codes. Patients with spine infections who have received transplants were then identified using International Classification of Diseases, Ninth Revision codes for spine infection. In addition to demographic data, we recorded medical comorbidities, immunosuppressant medications, laboratory results, culture data, treatment received, and short-term results., Results: During this 6-year period, 2764 solid organ transplants were performed at our institution. Of this cohort, 6 patients (0.22%) were treated for a spinal infection. Patient's age ranged from 51 to 80 years (mean, 63 yr). All spine infections occurred within 1 year after organ transplantation. All patients had an elevated erythrocyte sedimentation rate. Only 1 patient had an elevated white blood cell count. The most common organisms were Escherichia coli and Staphylococcus. Four patients required surgical treatment. All patients had complete resolution of symptoms., Conclusion: Our data suggest that patients with a history of solid organ transplantation may be more susceptible to developing spine infections than the general population. The most common organisms in our cohort were E. coli and Staphylococcus. Spine infections caused by atypical organisms do also occur in the organ transplant population, as is the case in other immunocompromised patients. The identification of these organisms and timely institution of treatment remains critical in the management of this at-risk population., Level of Evidence: 4.

Objectives: To determine the long-term mortality and the causes of death after Staphylococcus aureus spondylodiscitis., Methods: Nationwide, population-based cohort study using national registries of adults diagnosed with non postoperative S. aureus spondylodiscitis from 1994-2009 and alive 1 year after diagnosis (n Z 313). A comparison cohort from the background population individually matched on sex and age was identified (n Z 1565). Kaplan-Meier survival curves were constructed and Poisson regression analyses used to estimate mortality rate ratios (MRR) adjusted for comorbidity., Results: 88 patients (28.1%) and 267 individuals from the population-based comparison cohort (17.1%) died. Un-adjusted MRR for S. aureus spondylodiscitis patients was 1.77 (95% CI, 1.39-2.25) and 1.32 (95% CI, 1.02-1.71) after adjustment for comorbidity. We observed increased mortality due to infectious (MRR 8.57; 95% CI, 2.80-26.20), endocrine (MRR 3.57; 95%CI, 1.01-12.66), cardiovascular (MRR 1.59; 95% CI, 1.02-2.49), gastrointestinal (MRR 3.21; 95% CI, 1.178.84) and alcohol and drug abuse-related (MRR 10.71; 95% CI, 3.23-35.58) diseases., Conclusions: Patients diagnosed with S. aureus spondylodiscitis have substantially increased long-term mortality, mainly due to comorbidity. To improve survival after S. aureus spondylodiscitis these patients should be screened for comorbidity and substance abuse predisposing to the disease [corrected]., (Copyright © 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

The diagnosis of anaerobic bone and joint infections (BJI) were underestimated before the advent of molecular identification and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). We report 61 cases of anaerobic infections based on our 4-year experience with the management of BJI. A total of 75% of cases were post-surgical infections, associated with osteosynthesis devices (65%). Early infections occurred in 27% of cases, delayed infections in 17.5% of cases, and late infections in 55% of cases. We recorded 36 species of 93 anaerobic strains using MALDI-TOF MS (91) and molecular methods (2). We identified 20 strains of Propionibacterium acnes, 13 of Finegoldia magna, six of Peptoniphilus asaccharolyticus, and six of P. harei. Polymicrobial infections occurred in 50 cases. Surgical treatment was performed in 93.5% of cases. The antibiotic treatments included amoxicillin (30%), amoxicillin-clavulanic acid (16%), metronidazole (30%), and clindamycin (26%). Hyperbaric oxygen therapy was used in 17 cases (28%). The relapse rate (27%) was associated with lower limbs localization (p = 0.001). P. acnes BJI was associated with shoulder (p = 0.019), vertebra (p = 0.021), and head flap localization (p = 0.011), and none of these cases relapsed (p = 0.007). F. magna BJI was associated with ankle localization (p = 0.014). Anaerobic BJI is typically considered as a post-surgical polymicrobial infection, and the management of this infection combines surgical and medical treatments. MALDI-TOF MS and molecular identification have improved diagnosis. Thus, physicians should be aware of the polymicrobial nature of anaerobic BJI to establish immediate broad-spectrum antibiotic treatment during the post-surgical period until accurate microbiological results have been obtained.

Fusobacterium spp. are Gram negative anaerobe bacteria. Vertebral osteomyelitis caused by these bacteria is very unusual; in fact, we could only find 11 cases in the literature. We report the case of a male, 46 year-old patient who had had lumbar pain for several weeks that irradiated to the right leg, and did not respond to NSAID treatment. The work-up included MRI, biopsy with draining of the collection and a universal PCR followed by 16S rDNA sequencing. The latter was used to make the microbiologic diagnosis, which identified Fusobacterium nucleatum as the causative agent. Final treatment consisted of clindamycin. In conclusion, spondylodiscitis due to Fusobacterium spp. is a rare and difficult to diagnose entity, due both to its clinical characteristics and to the difficulty in making the right microbiologic diagnosis. Vertebral biopsy and molecular microbiologic techniques such as Universal PCR rDNa, are essential to identifying the organism, making the diagnosis and prescribing appropriate antibiotic therapy.

Osteoarticular infections remain a significant cause of morbidity worldwide in young children. They can have a devastating impact with a high rate of serious and long-lasting sequelae, especially on remaining growth. Depending on the localisation of infection, they manifest as osteomyelitis, septic arthritis, a combination of both (i.e., osteomyelitis with adjacent septic arthritis) or spondylodiscitis. Osteoarticular infections can be divided into three types according to the source of infection: haematogenous; secondary to contiguous infection; or secondary to direct inoculation. During the last few years, many principles regarding diagnostic assays and the microbiological causes of these infections have evolved in a significant manner. In the present current-opinion review, we discuss recent concepts regarding epidemiology, physiopathology, and the microbiology of bone and joint infections in young children, as well as clinical presentations, diagnosis, and treatment of these infections. Clinicians caring for children need to be especially well versed in these newer concepts as they can be used to guide evaluation and treatment.

Spondylodiscitis caused by Parvimonas micra, a rarely reported infection, might be under-detected using conventional methods. This report of the detection and treatment of two cases of spondylodiscitis due to P. micra and review of the literature indicates that the use of gene sequencing methods might improve the accuracy of diagnosing this infection., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This is a retrospective study of 15 patients treated for spondylodiscitis with implanted metal cages. The purpose of this study is to investigate the outcomes of patients treated with permanently placed metal hardware in vertebral body reconstruction for spondylodiscitis. The use of metal implants in the face of infection has classically been discouraged in orthopedic literature because of the ability of bacteria to form biofilms on metal surfaces. Traditional treatment of spondylodiscitis has been aggressive debridement followed by reconstruction with bone grafts. Expandable metallic cages made reconstruction of these defects significantly easier. However, concern exists that metallic implants affect the resolution of infection. A search of the authors' patient database from 2005 to 2009 revealed 21 patients with spondylodiscitis treated with anterior debridement and reconstruction with an expandable metallic cage. Fourteen patients (15 cases) had sufficient documented clinical follow-up and were available for review. Resolution of infection was determined by evaluating symptoms, laboratory data, and final radiographic result. Of the 15 cases, all had clinical resolution of infection with an average follow-up time of 25 months. An average loss of 1.9° of correction was observed when comparing final follow-up radiographs with initial postoperative radiographs. Radiograph review revealed no extensive osteolysis around the hardware or progressive collapse. These results suggest that the use of expandable metal cages maintains alignment while not perpetuating infection. The spine appears to provide a unique environment that permits the use of metal implants in the setting of infection., (Copyright 2014, SLACK Incorporated.)

Background: Tigecycline is a relatively new glycylcycline antimicrobial, active in vitro against a variety of Gram-positive and Gram-negative organisms. In this study we evaluated the outcomes of spondylodiscitis cases treated with tigecycline-including therapies retrospectively., Methods: All adult (age >18 years) cases with a diagnosis of spondylodiscitis, who were treated with a tigecycline-including therapy between 2007 and 2011, were included in the study. The primary efficacy outcome was clinical success with tigecycline at the end of induction, while the secondary efficacy outcome was maintenance of success through 3 months following completion of induction., Results: A total of eight spondylodiscitis cases fulfilled the study inclusion criteria. All cases had back pain, restricted mobility, magnetic resonance findings associated with spondylodiscitis, and microbiology or pathological findings related to spondylodiscitis. All had post-neurosurgical spondylodiscitis. In five cases, tigecycline was started in accordance with the antibacterial susceptibility results from intervertebral tissue biopsy cultures, whereas in three it was started empirically. All cases had received several different antibacterials with failure before receiving tigecycline. The mean duration of tigecycline treatment was 37±21 days. One case was lost to follow-up after 2 days of tigecycline. Primary and secondary success was achieved in the remaining seven cases., Conclusions: These limited data suggest that tigecycline may have a role in the treatment of refractory spondylodiscitis cases., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Spondylodiscitis, which is most commonly caused by Staphylococcus aureus, is an uncommon infection in adults. The diagnosis of spondylodiscitis is often delayed by its vague and non-specific presentations. As part of the normal flora in human mouth and sinuses, Streptococcus mitis is a very rare cause of spondylodiscitis. We report a case of thoracic spondylodiscitis caused by S. mitis in a patient with chronic sinusitis. The patient atypically presented with a sharp chest pain that radiated to the back and the imaging studies were initially negative. He failed outpatient pain management and the diagnosis of spondylodiscitis was confirmed by bone biopsy 6 weeks later. Treatment with antibiotics completely alleviated the pain. Increased awareness and a high index of suspicion are essential for early diagnosis of spondylodiscitis with an atypical presentation., (2014 BMJ Publishing Group Ltd.)

Eggerthella lenta bacteremia is uncommon and generally associated with abdominal sepsis. The organism and its clinical significance have not been well characterized due to historical difficulties with identification. We report a case of severe infection in a paraplegic man complicated by psoas abscess, osteomyelitis, and meningitis and discuss treatment challenges.

Background: Spondylodiscitis, also known as vertebral osteomyelitis, is a destructive disease with high morbidity and mortality. Diagnosis is often delayed because of the rarity of the disease and the fact that early symptoms are often non-specific. There are currently no national guidelines on the diagnosis and treatment of spondylodiscitis in the Netherlands., Methods: We performed a single-centre retrospective cohort study examining 49 patients over 18 years of age treated for spondylodiscitis in a six-year time period., Results: Mean age of patients was 69 years (range 40-89). Most patients underwent an MRI scan to confirm diagnosis (n=30). In 39 patients a microorganism was found, most commonly Staphylococcus aureus (n=14), Streptococcus species (n=11) and Gram-negative bacteria (n=11). All patients were treated with antibiotics. Thirty-seven patients received antibiotic treatment for at least six weeks, while 17 patients were treated for 90 days or longer. In 13 patients no adequate treatment was started until culture results were available. Eleven patients underwent surgery after their diagnosis. Two patients had a recurrence., Conclusion: We recommend that, when considering spondylodiscitis as a possible diagnosis, all patients should undergo thorough physical examination, neurological screening, blood tests for infection and blood cultures. An MRI scan should be performed, followed by a PET-CT scan when results are inconclusive. Ideally a CT-guided biopsy is performed before treatment is started. Awaiting culture results all patients should receive broad-spectrum antibiotics. Targeting only Gram-positive microorganisms in empiric treatment will lead to a delay in adequate treatment in a substantial group of patients. A multidisciplinary approach is advocated.