2023 ESC Guidelines for the management of endocarditis.

Wulf Seeling give a comprehensive review of more than 915 patients with spinal epidural abscesses (SEA) collected from the literature over the last four decades. At the beginning they present an extensive historical review, with the first description of the disease from the eighteenth century and the unfavourable clinical outcomes before antibiotic therapy, despite operative laminectomy and evacuation. Thereafter, they evaluate nearly 400 papers on SEA from 1964 to 1997, describing epidemiology, pathogenesis, risk factors, clinical and laboratory findings, and diagnostic imaging techniques. They evaluate in detail the causative organism during SEA. Then they report on operative treatments and clinical outcome separately for each decade beginning with the 1950s. The authors could show that mortality continuously decreased to 15% and complete recovery improved from 28% to 47% and, since the 1980s, has constantly been in the range of about 45%. The only point I found missing are the authors’ personal conclusions from the huge amount of data, especially regarding the future treatment and management of these patients. Is conservative treatment as successful as operative treatment? If there is no neurologic deficit, should antibiotic therapy be performed first as therapy of choice? Sometimes these patients are in poor general condition with high perioperative risk. Should the operation nevertheless be performed as first step to evacuate the pus? From my personal experience, I would like to add some surgical questions and problems. In some cases, we could not find pus intraoperatively but mainly granulation tissue, which cannot easily be removed over a long distance. A second problem concerns cases where the empyema is in the whole epidural space from the cervical to the lumbar region. Is one laminectomy enough in these cases? How extended should it be? Should a hemilaminectomy be performed at every second level over a longer distance? Despite these questions and comments, this article gives an excellent review of spinal epidural abscesses, with meticulous evaluation and analysis of the published cases. It completely meets the expectations of a review article. P. Grunert

Spinal epidural abscess: a meta-analysis of 915 patients

Spinal infection poses a demanding diagnostic and treatment problem for which a multidisciplinary approach with spine surgeons, radiologists, and infectious disease specialists is required. Infections are usually caused by bacterial microorganisms, although fungal infections can also occur. The most common route for spinal infection is through hematogenous spread of the microorganism from a distant infected area. Most patients with spinal infections diagnosed in early stages can be successfully managed conservatively with antibiotics, bed rest, and spinal braces. In cases of gross or pending instability, progressive neurological deficits, failure of conservative treatment, spinal abscess formation, severe symptoms indicating sepsis, and failure of previous conservative treatment, surgical treatment is required. In either case, close monitoring of the patients with spinal infection with serial neurological examinations and imaging studies is necessary.

https://www.mdpi.com/2076-2607/8/4/476/pdf

Spinal Infections: An Update.

Spinal epidural empyema is defined an accumulation of purulent material in the epidural space of the vertebral canal. Spinal epidural empyema should be considered as a differential diagnosis in dogs with pyrexia, spinal pain, and rapidly progressing myelopathy. Magnetic resonance (MR) imaging is the imaging test of choice in humans. Here, we describe the MR imaging features of five dogs with confirmed spinal epidural empyema. The epidural lesions appeared as high or mixed signal masses in T2-weighted (T2W) images. Increased signal within the spinal cord gray matter at the site of the lesion was detected in T2W images in all dogs. Two patterns of enhancement were detected on postcontrast T1-weighted (T1W) images. Mild to moderate peripheral enhancement was seen in three dogs and a diffuse pattern of enhancement was seen in one. Discospondylitis was identified in three dogs on T1W postcontrast images. Decompressive spinal surgery was performed in all dogs. Bacteria isolated from the abnormal epidural tissue were Enterobacter cloacae, coagulase-positive Staphylococci, Pasteurella multocida, and Escherichia coli. In one dog bacteria were not isolated. These MR imaging features, along with appropriate clinical signs, can allow prompt diagnosis and appropriate treatment planning.

Magnetic resonance imaging features of spinal epidural empyema in five dogs.

OBJECTIVESpontaneous spondylodiscitis remains uncommon but is a serious complication of the vertebral column. Risk factors include diabetes, hemodialysis, intravenous drug abuse, and chronic steroid use, and pain is the most common presenting symptom. This study aims to review the literature and report on the incidence, management, and clinical outcome of spontaneous spondylodiscitis in 44 patients.METHODSThis is a prospective study including 44 patients with spontaneous spondylodiscitis managed in the neurosurgery department of Cairo University Hospitals during the period between January 2012 and October 2017. All patients had a full clinical assessment, laboratory tests, radiological studies in the form of MRI with and without contrast, and a postoperative follow-up of up to 12 months.RESULTSTwelve cases underwent conservative treatment in the form of complete bed rest, intravenous antibiotics, and a spinal brace. Ten cases underwent surgical intervention in the form of laminectomy, debridement, and open biopsy. Twenty-two cases underwent laminectomy and surgical stabilization with fusion. There were 15 cases of tuberculous spondylodiscitis, 6 cases of brucellosis, 6 cases of pyogenic infection, and 17 cases in which no organism could be detected.CONCLUSIONSOnce the primary diagnosis is confirmed, early and adequately prolonged antibiotic therapy is recommended for spontaneous spondylodiscitis. Some cases can be successfully treated with conservative treatment alone, whereas surgery may be needed in other cases such as severe destruction of endplates, spinal abscess formation, mechanical instability, neurological deficits, and severe pain that have failed to respond to conservative treatment.

/pdf/spontaneous-spondylodiscitis-review-incidence-management-and-bdcorbomnx.pdf

Spontaneous spondylodiscitis: review, incidence, management, and clinical outcome in 44 patients

Infections of the Spine.

A team approach among orthopaedic surgeons, infectious disease specialists, and patients is of paramount importance when treating periprosthetic joint infections (PJIs). Treatment usually includes various surgical approaches along with antibiotic treatment. Antibiotic selection requires a multifactorial decision that depends on the organism that is identified, its antibiotic-resistance profile, the extent of the infection, and factors associated with the host. Antibiotic duration is dependent on surgical intervention and the type of organism. Typically, patients are treated for 6 weeks after debridement, antibiotics, and implant retention (DAIR) and for 4 to 6 weeks after single-stage and 2-stage revision arthroplasty. Levofloxacin in combination with rifampin has shown favorable outcomes for Staphylococcus PJI treatment. Quinolones have excellent bioavailability and bone and joint concentrations. Ciprofloxacin can be used for sensitive gram-negative infections. Evidence is emerging that supports the use of oral antibiotics after 7 days of intravenous antibiotics for the treatment of PJI. Although this should be considered carefully, it can potentially alleviate the burden on patients and caregivers, with fewer intravenous lines and the potential for fewer complications.

Periprosthetic Joint Infection: A Review of Antibiotic Treatment.

BACKGROUND Necrotizing fasciitis is a rare infection with rapid deterioration and a high mortality rate. Factors associated with in-hospital mortality have not been thoroughly evaluated. Although predictive models identifying the diagnosis of necrotizing fasciitis have been described (such as the Laboratory Risk Indicator for Necrotizing Fasciitis [LRINEC]), their use in predicting mortality is limited. QUESTIONS/PURPOSES (1) What demographic factors are associated with in-hospital mortality in patients with necrotizing fasciitis? (2) What clinical factors are associated with in-hospital mortality? (3) What laboratory values are associated with in-hospital mortality? (4) Is the LRINEC score useful in predicting mortality? METHODS We retrospectively studied all patients with necrotizing fasciitis at our tertiary care institution during a 10-year period. In all, 134 patients were identified; after filtering out patients with missing data (seven) and those without histologically confirmed necrotizing fasciitis (12), 115 patients remained. These patients were treated with early-initiation antibiotic therapy and aggressive surgical intervention once the diagnosis was suspected. Demographic data, clinical features, laboratory results, and treatment variables were identified. The median age was 56 years and 42% of patients were female. Of the 115 patients analyzed, 15% (17) died in the hospital. Univariate and receiver operating characteristic analyses were performed due to the low number of mortality events seen in this cohort. RESULTS The demographic factors associated with in-hospital mortality were older age (median: 64 years for nonsurvivors [interquartile range (IQR) 57-79] versus 55 years for survivors [IQR 45-63]; p = 0.002), coronary artery disease (odds ratio 4.56 [95% confidence interval (CI) 1.51 to 14]; p = 0.008), chronic kidney disease (OR 4.92 [95% CI 1.62 to 15]; p = 0.006), and transfer from an outside hospital (OR 3.47 [95% CI 1.19 to 10]; p = 0.02). The presenting clinical characteristics associated with in-hospital mortality were positive initial blood culture results (OR 4.76 [95% CI 1.59 to 15]; p = 0.01), lactic acidosis (OR 4.33 [95% CI 1.42 to 16]; p = 0.02), and multiple organ dysfunction syndrome (OR 6.37 [95% CI 2.05 to 20]; p = 0.002). Laboratory values at initial presentation that were associated with in-hospital mortality were platelet count (difference of medians -136 [95% CI -203 to -70]; p < 0.001), serum pH (difference of medians -0.13 [95% CI -0.21 to -0.03]; p = 0.02), serum lactate (difference of medians 0.90 [95% CI 0.40 to 4.80]; p < 0.001), serum creatinine (difference of medians 1.93 [95% CI 0.65 to 3.44]; p < 0.001), partial thromboplastin time (difference of medians 8.30 [95% CI 1.85 to 13]; p = 0.03), and international normalized ratio (difference of medians 0.1 [95% CI 0.0 to 0.5]; p = 0.004). The LRINEC score was a poor predictor of mortality with an area under the receiver operating characteristics curve of 0.56 [95% CI 0.45-0.67]. CONCLUSIONS Factors aiding clinical recognition of necrotizing fasciitis are not consistently helpful in predicting mortality of this infection. Identifying patients with potentially compromised organ function should lead to aggressive and expedited measures for diagnosis and treatment. Future multicenter studies with larger populations and a standardized algorithm of treatment triggered by high clinical suspicion can be used to validate these findings to better help prognosticate this potentially fatal diagnosis.Level of Evidence Level III, therapeutic study.

What Demographic and Clinical Factors Are Associated with In-hospital Mortality in Patients with Necrotizing Fasciitis?

Septic Arthritis of an Atlantoaxial Facet Joint with Normal Inflammatory Markers: Case Report and Literature Review.

Osteoarticular infections (OAIs) in the setting of infective endocarditis (IE) are uncommon. Although morbidity and mortality have been widely studied, details of the characteristics of patients with concurrent IE and OAI are limited. Therefore, the purpose of this study was to determine the (1) incidence, (2) mortality, (3) clinical features, and (4) microbiological profiles of OAIs in the setting of IE. A retrospective review was conducted of 1280 IE cases at a large academic institution between 2009 and 2015. Patients were categorized according to the following OAI types: spondylodiskitis, large joint septic arthritis, other site infections, or multiple affected joints. Inpatient mortality rates, clinical findings, and microbiological characteristics were compared between OAI types. Overall, the incidence of OAI among IE patients was 6.8% (n=87). The in-hospital mortality rate was 9.2% (n=8) and was not significantly associated with OAI type (P=.801). Eighteen patients had multiple affected joints resulting in a total of 114 infected sites. Of these, 39% (n=44) were spondylodiskitis, 29% (n=33) were large joint septic arthritis, and 32% (n=37) were infections of smaller joints. Back pain was most common among patients with spondylodiskitis (P<.001), whereas fever and general fatigue were most common with septic arthritis (P<.001). Of the available bone/ joint cultures, 69% were positive. Overall, Staphylococcus aureus was the most common IE pathogen in patients with both IE and OAI (63%). Clinicians should maintain a high suspicion for OAI in patients with IE caused by Staphylococcus aureus, particularly spondylodiskitis among those presenting with back pain. [Orthopedics 2020; 43(1):24-29.].

Incidence and Characteristics of Osteoarticular Infections in Patients With Infective Endocarditis.

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