Clinical and Radiological Analysis of Pyogenic Vertebral Osteomyelitis Immediately after Successful Antimicrobial Therapy: Considerations for Assessing Therapeutic Response

Purpose: The clinical and radiological abnormal findings continue even after successful treatment in pyogenic vertebral osteomyelitis (PVO). We analyzed the clinical and radiological features of cured PVO based on 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging (FDG-PET/MRI) and compared the radiological differences between FDG-PET and MRI for assessing therapeutic response in PVO. Methods: This study included 43 patients (28 men and 15 women) with lumbar PVO who had no recurrence after successful antimicrobial therapy. They were divided into two groups based on the location of maximum standardized FDG uptake value (SUVmax) of PVO lesion on FDG-PET/MRI when parenteral antibiotics were discontinued (31 in group A: Intervertebral structure; 12 in group B: Vertebral body and paravertebral muscle). The differences of clinical symptoms, hematological inflammatory indices, and radiological features were retrospectively analyzed. Results: The patients were treated with 42.28 ± 14.58 (21–89) days of parenteral antibiotics. There were significant differences in C-reactive protein (0.97 ± 1.10 vs. 0.51 ± 0.31 mg/dL, p = 0.041; normal range of CRP < 0.5), back pain (4.29 ± 1.13 vs. 3.50 ± 1.00, p = 0.040; visual analog scale), and SUVmax (4.34 ± 1.24 vs. 5.89 ± 1.57, p < 0.001) between the two groups. In the distribution pattern of PVO lesions, FDG-PET overall showed recovery pattern earlier than MRI did (p < 0.001). Conclusions: In cured PVO, the clinical features vary depending on the location of major structural damage of PVO lesion. The involvement of intervertebral structure is related with sustained back pain and elevation of CRP, and vertebral body/paravertebral muscle shows favorable clinical features despite advanced structural damages.

Download Full-text

Clinical and Radiological Features Predicting Intervertebral Autofusion after Successful Antibiotic Therapy in Pyogenic Vertebral Osteomyelitis

Diagnostics ◽

10.3390/diagnostics11081349 ◽

2021 ◽

Vol 11 (8) ◽

pp. 1349

Author(s):

Insu Seong ◽

Eunjung Kong ◽

Ikchan Jeon

Keyword(s):

Back Pain ◽

Antibiotic Therapy ◽

Fdg Pet ◽

Soft Tissues ◽

Vertebral Osteomyelitis ◽

Fdg Uptake ◽

Radiological Features ◽

Group A ◽

Pyogenic Vertebral Osteomyelitis ◽

18F Fdg

Background: Pyogenic vertebral osteomyelitis (PVO) is a bacterial infection involving the intervertebral disc, vertebral body, and paravertebral soft tissues. Damaged intervertebral structure is a major cause of persistent back pain even after successful antibiotic therapy, which can be improved by achieving autofusion or via additional surgical fixation. In this study, we analyzed the clinical and radiological features predicting intervertebral autofusion after successful antibiotic therapy in lumbar PVO. Methods: This study was retrospectively conducted with 32 patients (20 men and 12 women) diagnosed with lumbar PVO that was completely cured with no recurrences after antibiotic therapy. They were divided into two groups with (group A, n = 18) and without (group B, n = 14) intervertebral autofusion at six-month follow-up. Differences in back pain, blood inflammatory markers, and radiological features of PVO on simultaneous 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging (18F-FDG-PET/MRI) of the intervertebral structure between the two groups were analyzed. Results: The mean duration of antibiotic therapy was 41.44 ± 14.21 (21–89) days. Group A showed a statistically higher erythrocyte sedimentation ratio (ESR; 59.28 ± 32.33 vs. 33.93 ± 18.76 mm/h, p = 0.014; normal range of ESR < 25), maximum standardized 18F-FDG uptake (SUVmax; 5.56 ± 1.86 vs. 3.98 ± 1.40, p = 0.013), and sustained extensive edematous changes on T2-weighted fat saturation (T2FS) MRI (p = 0.015) immediately after successful antibiotic therapy. However, no significant differences were observed in back pain, C-reactive protein, or the distribution of 18F-FDG uptake/contrast enhancement on 18F-FDG-PET/MRI (p > 0.05). Conclusions: Higher ESR and SUVmax of the intervertebral structure and sustained extensive edematous change on T2FS MRI immediately after successful antibiotic therapy are related with subsequent intervertebral autofusion, which should be carefully considered when assessing therapeutic response in PVO.

Download Full-text

Antimicrobial therapy and assessing therapeutic response in culture-negative pyogenic vertebral osteomyelitis: a retrospective comparative study with culture-positive pyogenic vertebral osteomyelitis

10.21203/rs.3.rs-42510/v1 ◽

2020 ◽

Author(s):

Dongwoo Yu ◽

Sang Woo Kim ◽

Ikchan Jeon

Keyword(s):

Back Pain ◽

Antimicrobial Therapy ◽

Therapeutic Response ◽

Vertebral Osteomyelitis ◽

Oral Antibiotics ◽

Normal Range ◽

Vas Score ◽

Pyogenic Vertebral Osteomyelitis ◽

Culture Positive ◽

Culture Negative

Abstract Background There are still controversies over the treatment and outcomes in culture-negative pyogenic vertebral osteomyelitis (PVO). The purpose of this study is to investigate the antimicrobial therapy, assessment of therapeutic response, and outcome of culture-negative PVO compared to culture-positive PVO. Methods Retrospective study was performed with non-surgical lumbar PVO. The patients were divided into two groups based on the causative bacterial identification (CN group with culture-negative and CP group with culture-positive). The clinical features, use of antibiotics, laboratory data, and outcomes were compared between the two groups. Results Seventy-three patients with 41 (56.2%) of the CN group and 32 (43.8%) of the CP group were enrolled. Group CN showed a shorter duration of parenteral antibiotics (45.88 ± 16.14 vs. 57.31 ± 24.39, p = 0.019) although a tendency of prolonged duration of total (parenteral + oral) antibiotics (101.17 ± 52.84 vs. 84.19 ± 50.29 days, p = 0.168). When parenteral antibiotics were discontinued or switched to oral antibiotics, erythrocyte segmentation rate (ESR, normal range: < 20 mm/h), C-reactive protein (CRP, normal range: < 0.5 mg/dL), and visual analogue scale (VAS) score for back pain were 42.86 ± 24.05 mm/h, 0.91 ± 1.18 mg/dL, and 4.05 ± 1.07, respectively, with no significant differences between the two groups. The recurrence rates of CN and CP groups were 7.3% (3/41) and 6.3% (2/32), respectively (p = 1.000). Conclusions CN group required a shorter duration of parenteral antibiotics than CP group. Discontinuation of parenteral antibiotics or changing administration route can be considered based on the values of ESR, CRP, and VAS score for back pain.

Download Full-text

Antimicrobial therapy and assessing therapeutic response in culture-negative pyogenic vertebral osteomyelitis: a retrospective comparative study with culture-positive pyogenic vertebral osteomyelitis

BMC Infectious Diseases ◽

10.1186/s12879-020-05669-1 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Dongwoo Yu ◽

Sang Woo Kim ◽

Ikchan Jeon

Keyword(s):

Back Pain ◽

Therapeutic Response ◽

Epidural Abscess ◽

Vertebral Osteomyelitis ◽

Bacterial Identification ◽

Oral Antibiotics ◽

Normal Range ◽

Pyogenic Vertebral Osteomyelitis ◽

Culture Positive ◽

Culture Negative

Abstract Background There are still controversies regarding the treatment and outcomes in culture-negative pyogenic vertebral osteomyelitis (PVO). The purpose of this study is to investigate the antimicrobial therapy, assessment of therapeutic response, and outcome of culture-negative PVO compared to culture-positive PVO. Methods A retrospective study was performed with non-surgical lumbar PVO patients. The patients were divided into two groups based on the causative bacterial identification (CN group with culture-negative PVO and CP group with culture-positive PVO). The clinical features, use of antibiotics, laboratory data, and outcomes were compared between the two groups. Results Seventy-three patients with 41 (56.2%) of the CN group and 32 (43.8%) of the CP group were enrolled. The CN group showed a shorter duration of parenteral antibiotics (45.88 ± 16.14 vs. 57.31 ± 24.39, p = 0.019) but a tendency of prolonged duration of total (parenteral + oral) antibiotics (101.17 ± 52.84 vs. 84.19 ± 50.29 days, p = 0.168). When parenteral antibiotics were discontinued or switched to oral antibiotics, the mean erythrocyte segmentation rate (ESR, normal range: < 25 mm/h), C-reactive protein (CRP, normal range: < 0.5 mg/dL) level, and visual analog scale (VAS) score of back pain were 42.86 ± 24.05 mm/h, 0.91 ± 1.18 mg/dL, and 4.05 ± 1.07, respectively, with no significant differences between the two groups. The recurrence rates of CN and CP groups were 7.3% (3/41) and 6.3% (2/32), respectively (p = 1.000). The presence of epidural abscess was the most significant factor for the identification of causative bacteria (p = 0.002), and there was no significant relationship between the use of empirical antibiotics before tissue culture and the causative bacterial identification (p = 0.194). Conclusions The CN group required a shorter duration of parenteral antibiotics than the CP group. Discontinuation of parenteral antibiotics or changing the administration route can be considered based on the values of ESR, CRP, and VAS score of back pain. The presence of epidural abscess was the most significant factor for the identification of causative bacteria.

Download Full-text

Antimicrobial therapy and assessing therapeutic response in culture-negative pyogenic vertebral osteomyelitis: a retrospective comparative study with culture-positive pyogenic vertebral osteomyelitis

10.21203/rs.3.rs-42510/v2 ◽

2020 ◽

Author(s):

Dongwoo Yu ◽

Sang Woo Kim ◽

Ikchan Jeon

Keyword(s):

Back Pain ◽

Therapeutic Response ◽

Epidural Abscess ◽

Vertebral Osteomyelitis ◽

Bacterial Identification ◽

Oral Antibiotics ◽

Normal Range ◽

Pyogenic Vertebral Osteomyelitis ◽

Culture Positive ◽

Culture Negative

Abstract Background: There are still controversies regarding the treatment and outcomes in culture-negative pyogenic vertebral osteomyelitis (PVO). The purpose of this study is to investigate the antimicrobial therapy, assessment of therapeutic response, and outcome of culture-negative PVO compared to culture-positive PVO.Methods: A retrospective study was performed with non-surgical lumbar PVO patients. The patients were divided into two groups based on the causative bacterial identification (CN group with culture-negative PVO and CP group with culture-positive PVO). The clinical features, use of antibiotics, laboratory data, and outcomes were compared between the two groups.Results: Seventy-three patients with 41 (56.2%) of the CN group and 32 (43.8%) of the CP group were enrolled. The CN group showed a shorter duration of parenteral antibiotics (45.88 ± 16.14 vs. 57.31 ± 24.39, p = 0.019) but a tendency of prolonged duration of total (parenteral + oral) antibiotics (101.17 ± 52.84 vs. 84.19 ± 50.29 days, p = 0.168). When parenteral antibiotics were discontinued or switched to oral antibiotics, the mean erythrocyte segmentation rate (ESR, normal range: < 25 mm/h), C-reactive protein (CRP, normal range: < 0.5 mg/dL) level, and visual analog scale (VAS) score of back pain were 42.86 ± 24.05 mm/h, 0.91 ± 1.18 mg/dL, and 4.05 ± 1.07, respectively, with no significant differences between the two groups. The recurrence rates of CN and CP groups were 7.3% (3/41) and 6.3% (2/32), respectively (p=1.000). The presence of epidural abscess was the most significant factor for the identification of causative bacteria (p = 0.002), and there was no significant relationship between the use of empirical antibiotics before tissue culture and the causative bacterial identification (p = 0.194).Conclusions: The CN group required a shorter duration of parenteral antibiotics than the CP group. Discontinuation of parenteral antibiotics or changing the administration route can be considered based on the values of ESR, CRP, and VAS score of back pain. The presence of epidural abscess was the most significant factor for the identification of causative bacteria.

Download Full-text

Validity of Clinical Assessment Using Clinical Symptoms and C-Reactive Protein for Therapeutic Response in Pyogenic Vertebral Osteomyelitis: Analysis Based on 18F-FDG-PET

Medicina ◽

10.3390/medicina57080809 ◽

2021 ◽

Vol 57 (8) ◽

pp. 809

Author(s):

Ikchan Jeon ◽

Dongwoo Yu ◽

Eunjung Kong

Keyword(s):

Antibiotic Therapy ◽

Clinical Assessment ◽

Fdg Pet ◽

Therapeutic Response ◽

Clinical Symptoms ◽

Vertebral Osteomyelitis ◽

Parenteral Antibiotic ◽

Reactive Protein ◽

Pyogenic Vertebral Osteomyelitis ◽

18F Fdg

Backgroundand objectives: The clinical assessment of therapeutic response in pyogenic vertebral osteomyelitis (PVO) has been usually performed based on the changes of clinical symptoms and blood inflammatory markers. Recently, 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) has emerged as an alternative independent method. We analyzed the validity of the clinical assessment for detecting residual PVO based on 18F-FDG-PET. Materials and Methods: This study was conducted with 53 patients confirmed as lumbar PVO under retrospective design. All patients underwent clinical assessment using clinical symptoms and C-reactive protein (CRP) for therapeutic response after parenteral antibiotic therapy, which led to the decision of placement in the uncontrolled (group UC) or controlled (group C) group. The validity of clinical assessment was analyzed based on the cut-off values of FDG uptake for detecting residual PVO as references, which are already established in the previous literature. Results: The mean duration of parenteral antibiotic therapy and recurrence rate were 42.19 ± 15.84 (21–89) days and 9.4% (5/53), respectively. 18F-FDG-PETs were performed at 80 rounds of clinical assessment on 37.40 ± 13.15 (21–83) days of parenteral antibiotic therapy and divided: 31 into group UC and 49 into group C, according to the decisions of clinical assessment. Based on the cut-off values of FDG uptake, clinical assessment showed 48.4–58.1% of false positive for residual PVO in group UC. However, 18F-FDG-PET showed 8.2% (4/49) of false negative for residual PVO in group C, which led to recurrences. Conclusions: Clinical assessment using clinical symptoms and CRP for evaluating therapeutic response in PVO is still a useful method in terms of similar recurrence rate compared to 18F-FDG-PET. However, the high rate of false positive for residual PVO can prolong the use of unnecessary antibiotics and overall treatment period.

Download Full-text

Antimicrobial therapy and assessing therapeutic response in culture-negative pyogenic vertebral osteomyelitis: a retrospective comparative study with culture-positive pyogenic vertebral osteomyelitis

10.21203/rs.3.rs-42510/v3 ◽

2020 ◽

Author(s):

Dongwoo Yu ◽

Sang Woo Kim ◽

Ikchan Jeon

Keyword(s):

Back Pain ◽

Therapeutic Response ◽

Epidural Abscess ◽

Vertebral Osteomyelitis ◽

Bacterial Identification ◽

Oral Antibiotics ◽

Normal Range ◽

Pyogenic Vertebral Osteomyelitis ◽

Culture Positive ◽

Culture Negative

Download Full-text

Assessment of Therapeutic Response in Pyogenic Vertebral Osteomyelitis Using 18F-FDG-PET/MRI

Diagnostics ◽

10.3390/diagnostics10110916 ◽

2020 ◽

Vol 10 (11) ◽

pp. 916

Author(s):

Ikchan Jeon ◽

Eunjung Kong ◽

Sang Woo Kim ◽

Ihn Ho Cho ◽

Cheol Pyo Hong

Keyword(s):

Fdg Pet ◽

Therapeutic Response ◽

Vertebral Osteomyelitis ◽

Standardized Uptake Value ◽

Clinical Assessments ◽

Fdg Uptake ◽

Reactive Protein ◽

Positron Emission ◽

Pyogenic Vertebral Osteomyelitis ◽

Magnetic Resonance Imaging Mri

Purpose: There is still no definite method to determine therapeutic response in pyogenic vertebral osteomyelitis (PVO). We analyzed the value of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for assessing therapeutic response in PVO. Methods: This retrospective study included 53 patients (32 men and 21 women) with lumbar PVO. The results of clinical assessments for therapeutic response were divided into “Cured” (group C) and “Non-cured” (group NC). The differences in clinical and radiological features of PVO lesions between the two groups were analyzed using clinical data and simultaneous FDG-PET/magnetic resonance imaging (MRI) obtained at each clinical assessment. Results: Clinical assessments and FDG-PET/MRIs were performed at 41.89 ± 16.08 (21–91) days of parenteral antibiotic therapy. There were 39 patients in group C and 14 in group NC. Diagnostic accuracies (DAs) of FDG uptake intensity-based interpretation and C-reactive protein (CRP) for residual PVO were as follows (p < 0.01): 84.9% of the maximum standardized uptake value of PVO lesion (PvoSUVmax), 86.8% of ΔPvoSUVmax−NmlSUVmax (SUVmax of normal vertebra), 86.8% of ΔPvoSUVmax−NmlSUVmean (SUVmean of normal vertebra), and 71.7% of CRP. DAs were better (92.5–94.3%) when applying FDG uptake intensity-based interpretation and CRP together. Under the FDG uptake distribution-based interpretation, FDG uptake was significantly limited to intervertebral structures in group C (p = 0.026). Conclusion: The interpretations of intensity and distribution of FDG uptake on FDG-PET are useful for detecting residual PVO in the assessment of therapeutic response of PVO. The combination of FDG-PET and CRP is expected to increase DA for detecting residual PVO.

Download Full-text

Long-Term Outcome of Pyogenic Vertebral Osteomyelitis: A Cohort Study of 260 Patients

Open Forum Infectious Diseases ◽

10.1093/ofid/ofu107 ◽

2014 ◽

Vol 1 (3) ◽

Cited By ~ 31

Author(s):

Arjun Gupta ◽

Todd J. Kowalski ◽

Douglas R. Osmon ◽

Mark Enzler ◽

James M. Steckelberg ◽

...

Keyword(s):

Cohort Study ◽

Back Pain ◽

Treatment Failure ◽

Vertebral Osteomyelitis ◽

Term Outcome ◽

Duration Of Symptoms ◽

Long Term Outcome ◽

Increased Risk ◽

Pyogenic Vertebral Osteomyelitis

Abstract Background. The long-term outcome of patients with pyogenic vertebral osteomyelitis (PVO) has not been fully assessed. Methods. We conducted a retrospective cohort study to describe the long-term outcome of PVO and to assess risk factors for treatment failure in patients evaluated at our institution between 1994 and 2002. Patients were observed until July 1, 2013. Results. Two hundred sixty patients with PVO were included in this study. Twenty-seven percent (70) of patients developed their infection after an invasive spinal procedure. Staphylococcus aureus accounted for 40% (103) of infections. Forty-nine percent (128) of patients underwent spinal surgery as part of their initial therapy. The median duration of parenteral antimicrobial therapy was 42 days (interquartile range, 38–53). The estimated 2-, 5-, and 10-year cumulative probability of treatment failure-free survival was 72%, 69%, and 69%, respectively. Seventy-five percent of patients who developed treatment failure did so within 4.7 months of diagnosis. Residual neurological defects and persistent back pain were seen in 16% and 32% of patients, respectively. In a multivariate analysis, longer duration of symptoms before diagnosis and having an infection with S. aureus were associated with increased risk of treatment failure. Conclusions. Increasing duration of symptoms and infection with S. aureus were associated with treatment failure in patients with PVO. Most treatment failures occurred early after initiation of treatment. Pyogenic vertebral osteomyelitis is associated with a high 2-year failure rate. Persistent neurological deficits and back pain are common after therapy.

Download Full-text