Guideline sources The following summarized guidelines for the evaluation and management of vertebral osteomyelitis are prepared by our editorial team based on guidelines from the French Society of Infectious Diseases (SPLIF 2023), the Infectious Diseases Society of America (IDSA/PIDS 2021), the American College of Radiology (ACR 2021), the European Association of Nuclear Medicine (EANM/ESNR/ESCMID 2019), and the Infectious Diseases Society of America (IDSA 2016; 2015; 2011). 1 2 3 4 5 6 7 8 Pathway Vertebral osteomyelitis Diagnosis and management Guidelines https://web.pathway.md/diseases/recycEtXL5346bLZc 1/9 6/29/23, 3:42 AM Vertebral osteomyelitis Pathway 1. Screening and diagnosis Diagnosis: As per SPLIF 2023 guidelines, suspect discovertebral infection in patients with any of the following: recent or worsening fever and spinal pain spinal pain associated with bacteremia and/or elevated CRP levels spinal pain associated with fever and/or elevated CRP levels fever and/or spinal pain and/or an elevated CRP level and/or a scarring disorder following a percutaneous spinal or peri-spinal procedure. E As per IDSA 2015 guidelines: Suspect native vertebral osteomyelitis in patients with new or worsening back or neck pain and any of the following: fever elevated ESR or CRP bloodstream infection or infective endocarditis. B Consider suspecting native vertebral osteomyelitis in patients presenting with any of the following: fever and new neurologic symptoms with or without back pain new localized neck or back pain, following a recent episode of S. aureus bloodstream infection. C 2. Diagnostic investigations History and physical examination: perform a pertinent medical and motor/sensory neurologic examination in patients with suspected native vertebral osteomyelitis. B Inflammatory markers: As per SPLIF 2023 guidelines, obtain CRP in the initial assessment of discovertebral infection. Do not obtain procalcitonin or ESR. E As per IDSA 2015 guidelines, obtain a baseline measurement of ESR and CRP levels in all patients with suspected native vertebral osteomyelitis. B Blood culture: As per SPLIF 2023 guidelines, obtain at least 2 pairs of aerobic/anaerobic blood cultures, with a volume of 10 mL, before initiating antibiotic therapy for the initial diagnosis of febrile or nonfebrile discovertebral infection. E As per ESCMID 2019 guidelines, obtain blood cultures for both aerobic and anaerobic bacteria in all patients with suspected spondylodiscitis. B https://web.pathway.md/diseases/recycEtXL5346bLZc 2/9 6/29/23, 3:42 AM Vertebral osteomyelitis Pathway As per IDSA 2015 guidelines: Obtain 2 sets of bacterial blood cultures (aerobic and anaerobic) in all patients with suspected native vertebral osteomyelitis. B Consider obtaining fungal blood cultures in patients with suspected native vertebral osteomyelitis at risk for fungal infection (epidemiologic risk or host risk factors). C Spinal imaging: As per SPLIF 2023 guidelines, obtain MRI as first-line evaluation, ideally within 72 hours in the absence of neurological complications, or at the start of follow-up in the event of complications, except in the early postoperative context. Include exploration of the entire spine and at least 2 orthogonal planes (sagittal and axial) at the affected levels, with sagittal T1-weighted, T2-weighted with fat suppression, and T1-weighted sequences after injection of gadolinium chelate. E Show 3 more As per ACR 2021 guidelines, obtain spinal MRI with or without IV contrast as the initial imaging in patients with suspected spinal infection (including discitis, osteomyelitis) in the following situations: new or worsening back or neck pain, with or without fever, likely having any red flags (diabetes mellitus, IV drug use, cancer, human immunodeficiency virus, or dialysis) or abnormal laboratory findings history of recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation) new neurologic deficit or cauda equina syndrome decubitus ulcer or wound overlying spine abnormal radiography or CT findings. (Usually Appropriate). B As per IDSA 2015 guidelines: Obtain spinal MRI in patients with suspected native vertebral osteomyelitis. B Consider obtaining a combination spinal gallium/technetium-99 bone scan, CT, or positron emission tomography in patients with suspected native vertebral osteomyelitis if MRI cannot be obtained (such as implantable cardiac devices, cochlear implants, claustrophobia, or unavailability). C Evaluation for endocarditis: Obtain evaluation for endocarditis in patients with confirmed discovertebral infection due to Staphylococcus, Streptococcus, or Enterococcus species, especially in the presence of bacteremia and/or intracardiac device. E Assess spinal stability before TEE for endocarditis in patients with a confirmed diagnosis of discovertebral infection at a cervical level. E Evaluation for tuberculosis: As per SPLIF 2023 guidelines, obtain a preliminary collection of less invasive samples (respiratory or lymph node) before performing discovertebral biopsy in patients with suspected spinal tuberculosis. E As per ESCMID 2019 guidelines, obtain a purified protein derivative test and an IGRA in patients with suspected spondylodiscitis and risk factors for Mycobacterium tuberculosis. B https://web.pathway.md/diseases/recycEtXL5346bLZc 3/9 6/29/23, 3:42 AM Vertebral osteomyelitis Pathway As per IDSA 2015 guidelines, consider obtaining a purified protein derivative test or an IGRA in patients with subacute native vertebral osteomyelitis at risk for Mycobacterium tuberculosis native vertebral osteomyelitis (originating or residing in endemic regions or having risk factors). C Evaluation for brucellosis: As per ESCMID 2019 guidelines, obtain specific serological tests for brucellosis in patients with suspected spondylodiscitis and epidemiological risk factors for brucellosis. B As per IDSA 2015 guidelines, obtain blood cultures and serologic tests for Brucella species in patients with subacute native vertebral osteomyelitis residing in endemic areas for brucellosis. B 3. Diagnostic procedures Biopsy and culture: As per SPLIF 2023 guidelines, perform a discovertebral biopsy to search for an infectious organism in patients with suspected discovertebral infection with sterile blood cultures. E Show 9 more As per IDSA 2015 guidelines, perform an image-guided aspiration biopsy in patients with suspected native vertebral osteomyelitis (based on clinical, laboratory, and imaging studies) when a microbiologic diagnosis for a known associated organism (S. aureus, S. lugdunensis, and Brucella species) has not been established by blood cultures or serologic tests. B Show 7 more 4. Medical management Antimicrobial therapy, indications: As per SPLIF 2023 guidelines, evaluate for and treat an infectious source guided by the nature of the microorganism in case of a confirmed diagnosis of discovertebral infection. E As per IDSA 2015 guidelines, initiate empiric antimicrobial therapy in patients with neurologic compromise with or without impending sepsis or hemodynamic instability. B Show 2 more Antimicrobial therapy (regimens): administer cloxacillin (150 mg/kg/day) or cefazolin (80-100 mg/kg/day) IV at least QID or with a continuous infusion after a loading dose of 2 grams by slow IV route in patients with methicillin-susceptible staphylococcal discovertebral infection. E Show 11 more Antimicrobial therapy, duration: As per SPLIF 2023 guidelines: Continue antimicrobial treatment for 6 weeks in patients with documented uncomplicated discovertebral infection (with or without material) with good evolution. E Follow-up for a minimum duration of 1 year and 2 years after discontinuing antibiotics in patients with discovertebral infection without a device and with a device, respectively. E https://web.pathway.md/diseases/recycEtXL5346bLZc 4/9 6/29/23, 3:42 AM Vertebral osteomyelitis Pathway As per IDSA 2015 guidelines, complete a total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy in most patients with bacterial native vertebral osteomyelitis. B Show 2 more Corticosteroids: consider adding corticosteroids in the presence of neurological symptoms, if surgical treatment is impossible or contraindicated. E 5. Nonpharmacologic interventions Patient positioning: do not offer strict dorsal decubitus in the initial phase of discovertebral infection if there are no clinical or radiological signs of spinal instability and the pain is under control. D Immobilization: Assess for the need of wearing an immobilization brace following specialized consultation, depending on discovertebral stability, spinal level, and the physiological age of the patient. E Do not offer a brace after spinal osteosynthesis for the treatment of discovertebral infection with instability. D 6. Surgical interventions Indications for surgery: As per SPLIF 2023 guidelines, perform surgical decompression urgently in case of neurological deficiency (motor deficit or spinal cord compression). E As per IDSA 2015 guidelines, perform immediate surgical intervention in patients with neurologic compromise with or without impending sepsis or hemodynamic instability. B Show 3 more 7. Specific circumstances Pediatric patients (evaluation): consider obtaining serum CRP in the initial evaluation of patients with suspected acute hematogenous osteomyelitis. C Show 5 more Pediatric patients (management): initiate empiric antimicrobial therapy immediately in patients with presumed acute hematogenous osteomyelitis who are ill-appearing or have a rapidly progressive infection. B Show 10 more Pediatric patients (follow-up): consider obtaining sequential monitoring of serum CRP in addition to serial clinical evaluation to assess response to therapy in patients with suspected or confirmed acute hematogenous osteomyelitis receiving antimicrobial therapy. C Show 5 more https://web.pathway.md/diseases/recycEtXL5346bLZc 5/9 6/29/23, 3:42 AM Vertebral osteomyelitis Pathway Patients with postoperative osteomyelitis (evaluation): establish the diagnosis of early (< 1 month) surgical site infection clinically. Do not obtain FDG-positron emission tomography/CT. Consider obtaining CT or MRI to search for a collection. E Show 5 more Patients with postoperative osteomyelitis (management): Initiate broad-spectrum empiric antibiotic therapy immediately after surgery of spinal surgical site infection, including surgical implants, and adapt to the microorganisms subsequently. E Perform irrigation and debridement without device replacement or removal in the event of early (< 1 month) postoperative discovertebral infection. Replace or remove the osteosynthesis material in late infection (> 1 month). E Patients with MRSA osteomyelitis (evaluation): Obtain contrast-enhanced MRI as the imaging modality of choice, particularly for the detection of early osteomyelitis and associated soft-tissue disease. B Consider obtaining ESR and/or CRP to guide response to therapy. C Patients with MRSA osteomyelitis (management): insufficient evidence to recommend an optimal route of administration of antibiotic therapy. Consider initiating parenteral, oral, or initial parenteral therapy followed by oral therapy depending on individual patient circumstances. I Show 8 more Patients with Candida osteomyelitis: initiate fluconazole 400 mg (6 mg/kg) daily for 6-12 months or an echinocandin (caspofungin 50-70 mg/day, micafungin 100 mg/day, or anidulafungin 100 mg/day) for at least 2 weeks, followed by fluconazole 400 mg (6 mg/kg) daily for 6-12 months in patients with Candida osteomyelitis. B Show 2 more Patients with Aspergillus osteomyelitis: perform surgical intervention, if possible, and initiate voriconazole for the management of patients with Aspergillus osteomyelitis and arthritis. B 8. Follow-up and surveillance Indications for specialist referral: As per SPLIF 2023 guidelines: Consult a spine specialist to evaluate spinal stability in the initial phase of discovertebral infection. E Obtain an emergency medical-surgical consultation for any radicular pain in patients with discovertebral Infection. E As per IDSA 2015 guidelines, consider referring patients with suspected native vertebral osteomyelitis for evaluation by an infectious disease specialist and a spine surgeon. C Serial clinical assessment: obtain daily neurological assessment in the initial phase of discovertebral infection management. E Serial laboratory assessment: As per SPLIF 2023 guidelines: Obtain Monitoring of CRP level in patients with discovertebral infection. E https://web.pathway.md/diseases/recycEtXL5346bLZc 6/9 6/29/23, 3:42 AM Vertebral osteomyelitis Pathway Obtain biological monitoring of tolerance and efficacy of the treatment throughout the duration of treatment. E As per IDSA 2015 guidelines, consider monitoring systemic inflammatory markers (elevated ESR and/or CRP), in conjunction with clinical assessment, after approximately 4 weeks of antimicrobial therapy in patients with native vertebral osteomyelitis. C Serial imaging assessment: As per SPLIF 2023 guidelines: Do not obtain systematic follow-up MRI during the monitoring of a discovertebral infection with a good clinical and biological evolution. D Consider obtaining radiological evaluation from the front and side, such as the EOS (if accessible), to assess pelvic and vertebral statics during follow-up of a destructive discovertebral infection, recognizing that it has the advantage of being less irradiating. E As per IDSA 2015 guidelines: Do not obtain routine follow-up MRI in patients with native vertebral osteomyelitis with observed favorable clinical and laboratory response to antimicrobial therapy. D Consider obtaining a follow-up MRI to assess evolutionary changes of the epidural and paraspinal soft tissues in patients with native vertebral osteomyelitis deemed to have a poor clinical response to therapy. C Management of treatment failure: Consider obtaining systemic inflammatory markers (elevated ESR and CRP) in patients with native vertebral osteomyelitis and suspected treatment failure. Suspect treatment failure in case of unchanged or increasing values after 4 weeks of treatment. C Show 3 more Do not view persistent pain, residual neurologic deficits, elevated markers of systemic inflammation, or radiographic findings alone as treatment failure in treated patients with native vertebral osteomyelitis. D Clinical findings Symptoms Past medical history Back pain Brucellosis Chills Cellulitis Dysesthesia Diabetes mellitus Fever Human immunodeficiency virus infection Limb pain Immunocompromising condition Localized back pain Infective endocarditis Malaise Malignancy Muscle spasms Renal insufficiency Neck pain Sepsis Radicular pain Septic arthritis Sweating Tuberculosis Urinary retention UTI Weight loss https://web.pathway.md/diseases/recycEtXL5346bLZc 7/9 6/29/23, 3:42 AM Vertebral osteomyelitis Pathway Past surgical history Medication history Spinal surgery Long-term corticosteroids Vital signs Social history Tachycardia IV drug use Musculoskeletal exam Neurological exam Focal spinal tenderness Cauda equina syndrome Hyperreflexia Hematological findings Limb paralysis Limb paresis WBC count Radiculopathy Lab findings ESR serum CRP Imaging findings Bone marrow edema Periosteal reaction Spinal accumulation of radiotracer Studies 2019 OVIVA In patients being treated for bone or joint infection, oral antibiotic therapy was noninferior to IV antibiotic therapy with respect to definitive treatment failure at 1 year. Li HK et al. N Engl J Med. 2019 Jan 31. References 1. Berbari EF, Kanj SS, Kowalski TJ et al. 2015 Infectious Diseases Society of America IDSA Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015 Sep 15;61 6):e26 46. Open 2. Charles R Woods, John S Bradley, Archana Chatterjee et al. Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics. J Pediatric Infect Dis Soc. 2021 Sep 23;10 8 801 844. Open 3. Mantelas M, Katsiki N, Antonitsis P et al. 2022 SPILF Clinical Practice Guidelines for the Diagnosis and Treatment of Disco-Vertebral Infection in Adults. Infect Dis Now. 2023 Jan 20;S2666 9919 23 00009 X. Open https://web.pathway.md/diseases/recycEtXL5346bLZc 8/9 6/29/23, 3:42 AM Vertebral osteomyelitis Pathway 4. Catherine Liu, Arnold Bayer, Sara E Cosgrove et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children. Clin Infect Dis. 2011 Feb 1;52 3):e18 55. Open 5. Elena Lazzeri, Alessandro Bozzao, Maria Adriana Cataldo et al. Joint EANM/ESNR and ESCMID- endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults. Eur J Nucl Med Mol Imaging. 2019 Nov;46 12 2464 2487. Open 6. Expert Panel on Neurological Imaging, A Orlando Ortiz, Alex Levitt et al. ACR Appropriateness Criteria Suspected Spine Infection. J Am Coll Radiol. 2021 Nov;18 11S S488 S501. Open 7. Pappas PG, Kauffman CA, Andes DR et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62 4):e1 50. Open 8. Patterson TF, Thompson GR rd, Denning DW et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Aug 15;63 4):e1-e60. Open 9. Expert Panel on Musculoskeletal Imaging:, Francesca D Beaman, Paul F von Herrmann et al. ACR Appropriateness Criteria Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection Excluding Spine and Diabetic Foot). J Am Coll Radiol. 2017 May;14 5S S326 S337. Open 10. Expert Panel on Musculoskeletal Imaging, Jennifer L Pierce, Michael T Perry et al. ACR Appropriateness Criteria Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection Excluding Spine and Diabetic Foot): 2022 Update. J Am Coll Radiol. 2022 Nov;19 11S S473 S487. Open https://web.pathway.md/diseases/recycEtXL5346bLZc 9/9