Vertebral osteomyelitis Diagnosis and management Diagnosis IDSA Q Does the patient have new or worsening neck and back pain? Q Does the patient have one of the following: fever, elevated inflammatory markers, or bacteremia? Yes to all 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 No to any History and physical examination Perform a pertinent medical and motor/sensory neurologic examination in patients with suspected native vertebral osteomyelitis. B Inflammatory markers Obtain a baseline measurement of ESR and CRP levels in all patients with suspected native vertebral osteomyelitis. B Indications for specialist referral Consider referring patients with suspected native vertebral osteomyelitis for evaluation by an infectious disease specialist and a spine surgeon. C Spinal imaging IDSA Q Is spine MRI available? Yes 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 No Antimicrobial therapy Indications Q Does the patient have neurologic compromise? Q Does the patient have hemodynamic instability or sepsis? Yes to any Initiate empiric antimicrobial therapy in patients with neurologic compromise with or without impending sepsis or hemodynamic instability. B Consider holding empiric antimicrobial therapy until a microbiologic diagnosis is established in patients with normal and stable neurologic examination and stable hemodynamics. C Consider initiating empiric antimicrobial therapy in conjunction with an attempt at establishing a microbiologic diagnosis in patients with hemodynamic instability, sepsis, septic shock, or severe or progressive neurologic symptoms. C No to all Indications for surgery IDSA Q Does the patient have neurologic compromise? Q Does the patient have progressive neurologic deficits, deformity, or spinal instability despite adequate antimicrobial therapy? Q Does the patient have persistent or recurrent bloodstream infection or worsening pain despite appropriate antimicrobial therapy? Yes to any Perform immediate surgical intervention in patients with neurologic compromise with or without impending sepsis or hemodynamic instability. B Perform surgical intervention in patients with progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate antimicrobial therapy. B Consider performing surgical debridement with or without stabilization in patients with persistent or recurrent bloodstream infection (without an alternative source) or worsening pain despite appropriate medical therapy. C Do not perform surgical debridement and/or stabilization in patients witg worsening bony imaging findings at 4-6 weeks in the setting of improvement in clinical symptoms, physical examination, and inflammatory markers. D No to all Biopsy and culture IDSA Q Are blood cultures positive for an organism known to cause vertebral osteomyelitis (S. aureus, S. lugdunensis, Brucella species)? No 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 Do not perform an image-guided aspiration biopsy in patients with: S. aureus, S. lugdunensis, or Brucella species bloodstream infection suspected of having native vertebral osteomyelitis based on clinical, laboratory, and imaging studies suspected subacute native vertebral osteomyelitis (high endemic setting) and strongly positive Brucella serology. D Consider sending image-guided biopsy and aspiration specimens for fungal, mycobacterial, or brucella cultures in patients with suspected native vertebral osteomyelitis, if epidemiologic or host risk factors or characteristic radiologic clues are present. C Consider sending appropriately stored specimens for fungal and mycobacterial cultures and bacterial NAAT, if aerobic and anaerobic bacterial cultures reveal no growth in patients with suspected native vertebral osteomyelitis. C Send pathologic specimens from all patients, if adequate tissue can be safely obtained, to help confirm a diagnosis of native vertebral osteomyelitis and guide further diagnostic testing, especially in the setting of negative cultures. B Obtain a second aspiration biopsy in patients with suspected native vertebral osteomyelitis, in the absence of concomitant bloodstream infection, if the original image-guided aspiration biopsy specimen grew a skin contaminant (coagulase-negative staphylococci, except S. lugdunensis), Propionibacterium species, or diphtheroids). B Obtain further testing to exclude difficult-to-grow organisms (such as anaerobes, fungi, Brucella species, or mycobacteria) in patients with a nondiagnostic first image-guided aspiration biopsy and suspected native vertebral osteomyelitis. B Consider performing either a second image-guided aspiration biopsy, percutaneous endoscopic discectomy and drainage, or proceeding with an open excisional biopsy in patients with suspected native vertebral osteomyelitis and a nondiagnostic image- guided aspiration biopsy and laboratory workup. C Yes Antimicrobial therapy Duration Q Does the patient have Brucella infection? Yes Complete 3 months of antimicrobial therapy for most patients with native vertebral osteomyelitis due to Brucella species. B No Complete a total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy in most patients with bacterial native vertebral osteomyelitis. B Complete a total duration of 3 months of antimicrobial therapy in most patients with native vertebral osteomyelitis due to Brucella species. B Management of treatment failure Q Does the patient respond favorably to antimicrobial therapy? Yes 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 No 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 Obtain a follow-up MRI, emphasizing evolutionary changes in the paraspinal and epidural soft tissue findings, in patients with native vertebral osteomyelitis and suspected treatment failure. B Consider obtaining additional tissue samples for microbiologic (bacteria, fungal, and mycobacterial) and histopathologic examination, either by image-guided aspiration biopsy or through surgical sampling, in patients with native vertebral osteomyelitis and clinical and radiographic evidence of treatment failure. C Consider referring patients with native vertebral osteomyelitis and clinical and radiographic evidence of treatment failure for consultation with a spine surgeon and an infectious disease specialist. C