Spondylodiscitis Aetiology, diagnostics, therapy Cervical Spine Infections | USC Spine Center MUDr. Roman Stebel, Ph.D. MUDr. Jan Kocanda Department of Infectious Diseases Department of Orthopedic Surgery Faculty of Medicine, Masaryk University and University Hospital in Brno MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda MOTTO “Discitis from the infectologist’s and orthopaedist’s point of view” “Multidisciplinary issue = multidisciplinary approach” Obsah obrázku vázanka Popis byl vytvořen automaticky LogoSIL150b.gif MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda PRESENTATION PLAN ̶Definition ̶Epidemiology ̶Aetiopathogenesis ̶Clinical symptoms ̶Diagnostics ̶Imaging methods ̶Treatment ̶ ̶Case studies ̶Discussion Download High Quality Royalty Free Idea Plan Action S PowerPoint Icons and Idea Plan Action S 3D presentation graphics and icons MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Definition MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda By permission of: MUDr. V. Chmelík et al., České Budějovice Hospital, 2017 Anatomy – the localisation of the inflammatory process MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Epidemiology I MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Epidemiology II ̶Anatomical localisation: 50% LS, 40% Th, 10% C spine ̶ ̶Risk factors: ̶The elderly ̶Type 1 and 2 DM ̶Malignancies ̶Chronic renal failure, liver cirrhosis ̶Chronic cardiac failure, malnutrition ̶Severe obesity ̶HIV infection, alcohol abuse, narcotics ̶Trauma, smoking ̶ ̶ MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Pathogenesis ̶Pathophysiology ̶ ̶Pathogenic microbes ̶ ̶Inoculation – hematogenic – iatrogenic – per continuitatem ̶ ̶Neurogenic deficit ̶ ̶Other complications MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Pathogens ̶Aetiology is usually monobacterial, successfully identified only in ca two thirds of cases! ̶ ̶Staphylococcus aureus (ca 50% of discitis cases), including MRSA strains ̶Enterobacteria (E. coli, Proteus, Klebsiella, Enterobacter...), incl. ESBL+ ̶ ̶Mycobacterium tuberculosis (specific aetiology, developing countries) ̶Brucellosis (B. melitensis, B. abortus, the Mediterranean, Middle East) ̶Mycotic (in immunocompromised patients, ca 2%) Obsah obrázku červená Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Pathogenesis The diagnosis and management of discitis and spinal infection - Surgery - Oxford International Edition 1)The terminal vessels of spinal arteries end in vertebral bodies → septic emboli cause extensive bone infarctions → bone tissue defects, compressive fractures → instability of the spine, spread of infection to adjacent discs → destruction 2) 2)The infection spreads from the osteonecrotic lesions further into the paravertebral soft tissues and the epidural space of the spinal canal → abscesses, epidural empyema MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Clinical symptoms Obsah obrázku oblečení, osoba, plavky Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Clinical symptoms Clinical symptoms MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Clinical symptoms – neurology ̶Radiculopathy, myelopathy secondary to compression of nerve structures ̶Clinical image ranging from algoparesthesia, paraparesis and paraplegia to the cauda equina syndrome ̶Symptoms depend on the localisation of the inflammatory process: By permission of: MUDr. V. Chmelík et al., České Budějovice Hospital, 2017. Clinical symptoms MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda CAVE: “cold infection” (!) MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Diagnostics Diagnostics MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Imaging methods MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Imaging methods ̶Simple X-ray image of the spine ̶Computed tomography (CT) ̶Magnetic resonance imaging (MRI) ̶Scintigraphy, PET/MRI ̶ ̶ ̶ C Th St.p. dors. stabilizaci Th3-8 pro spondylodiscitis v et. Th5/6; nová spondylodiscitis v et. Th2/3 ̶ L ̶ ̶ ̶ ̶ pč 2 ̶ MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Diagnostics – haemocultivation ̶Haemocultivation sampling always before ATB initiation (risk of sterilisation of the cultures) ̶Vessel selection: aerobic (P. aeruginosa, Candida), anaerobic: strict anaerobes, viridising streptococci ̶1 pair (concurrent collection) = 1 haemoculture (!) ̶1 HMC is not enough, ideally 2 to 3 sets, sequential collection, increase of temperature / shivers ̶In patients with CVC, at least one HMC from the catheter, other from periphery ̶Vessel can be used also for CSF, centesis fluid, pus, exudate… ̶ Obsah obrázku text, elektronika Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Diagnostics – biopsy ̶Vertebral biopsy → targeted tissue collection from the lesion ̶For histology, cultivation, PCR diagnostics (bacteria, fungi) ̶Percutaneous CT-guided biopsy ̶Open (surgical) biopsy ̶ ̶Indication: ̶Finding infectious agent when empirical ATB therapy fails ̶Ruling out neoplastic aetiology in differential diagnostics Obsah obrázku text, několik Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Differential diagnostics ̶Erosive osteochondrosis ̶Compressive vertebral fracture ̶Neoplastic destruction ̶Plasmocytoma ̶Ankylosing spondylarthritis... ̶ ̶Test to find the lesion = origin (always with S. aureus bacteraemia): ̶Echocardiography (ideally transaesophageal ECHO) ̶US of the abdomen and intestines ̶X-ray of the chest ̶CT/MRI of the brain (abscess) ̶Ocular fundus examination ̶US of soft tissues/CT ̶ Obsah obrázku text, černá, fotka Popis byl vytvořen automaticky Vertebral plasmocytoma, Atlas of Pathology, University Hospital in Motol Obsah obrázku plíseň Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Differential diagnostics ̶Proof of G- aetiology (enterobacteria) → search for origin in GIT and UT ̶US or CT of the abdomen ̶GFS, colonoscopy ̶CT IVU, cystoscopy, TRUS... ̶ Obsah obrázku monitor, elektronika, kočka, interiér Popis byl vytvořen automaticky Obsah obrázku interiér Popis byl vytvořen automaticky Obsah obrázku text, kobliha Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Treatment ̶Always individual and multidisciplinary approach (!) ̶ ̶We must consider: ̶Neurological deficit ̶The extent of involvement ̶Biomechanical instability of the spine ̶Conservative treatment failure ̶Always also comorbidities, surgery risks, patient’s functional status ̶ ̶ ̶ ̶ ̶ ̶ CONSERVATIVE x SURGICAL Obsah obrázku stůl Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda ATB therapy Targeted according to haemocultivations Empirical ATB therapy Staphylococci: 1.Oxacillin IV 16–20 g/day 2.Vancomycin IV (MRSA) 30 mg/kg/day 3.Linezolide IV Initial parenteral: Oxacillin (vancomycin) + gentamicin, rifampicin Carbapenems (meropenem) Vancomycin + 3rd or 4th generation cephalosporin (or fluoroquinolone) Enterobacteria, G- bacilli 1.3rd or 4th generation cephalosporins 2.Combination with aminoglycosides 3.Monotherapy with carbapenems Following oral: Cotrimoxazole + rifampicin (affects biofilm) Doxycycline Clindamycin, cefuroxime axetil, linezolide... Streptococci: G-PNC, cephalosporins... ATB therapy MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Conservative treatment MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Conservative treatment ̶ATB therapy ̶Analgesia ̶Braces ̶Targeted RHB Obsah obrázku zeď, interiér, osoba Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Surgical treatment MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Magerl fixator Obsah obrázku interiér, spotřebič, kuchyňské spotřebiče Popis byl vytvořen automaticky Obsah obrázku text, rozmazání Popis byl vytvořen automaticky Obsah obrázku text, rozmazání Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Case study 1 MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Case study 1 MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Case study 1 MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Case study 1 Progression of Th10/11 spondylodiscitis, vertebral bodies completely involved, progression of perivertebral infiltration on the right Case study 1 MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Obsah obrázku konektor Popis byl vytvořen automaticky Obsah obrázku klipart Popis byl vytvořen automaticky Obsah obrázku osoba, interiér, zelená Popis byl vytvořen automaticky Obsah obrázku obuv Popis byl vytvořen automaticky MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Case study 1 MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Case study 1 – summary MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda OPAT (Outpatient Parenteral Antimicrobial Therapy) Continuing ATB therapy is usually necessary after discharge from hospitalisation a)A suitable oral drug exists → always prefer oral ATB b)No oral drug (agent + susceptibility, allergy...) → continue hospitalisation ...or OPAT! ATB regimens suitable for outpatient parenteral therapy of skeletal infections: •Amikacin, gentamicin 1x daily IV (multiresist. Pseudomonas aeruginosa) •Ertepenem 1x daily IV (ESBL strains of enterobacteria) •Teicoplanin 3x weekly IV (G+ cocci) • •Dalbavancin 1x weekly IV (MRSA, coagulase-negative staphylococci) → Lipoglycolpeptide ATB, biological half-life ca 180 hours → Lipophilic chain – good tissue penetration → Inhibits growth and multiplication of G+ bacteria 10x stronger than vancomycin MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda OPAT OPAT advantages: •Shortened hospitalisation •Reduced risk of nosocomial infections and other complications •Earlier restoration of mobility, return to regular activities, earlier RHB OPAT disadvantages: •Who, where and how will apply it? •The economical paradox – shortened hospitalisation according to DRG is often a disadvantage •ATB suitable for OPAT (dalbavancin) is expensive, approval by physician reviewer •Supervision concerning development of complications, recurrent disease... •Secured venous access (peripheral x central x PICC x midline catheter) MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda Discussion ̶Diagnostic delay (the interval from onset of complaint to determination of the correct diagnosis) is 10 weeks on average (2 to 6 months)! ̶ ̶Mortality and the presence of permanent neurological consequences both correlate with the delay in establishing the correct diagnosis ü50% of patients are over 50 years old üFever is present in 50% of cases üPhysiological peripheral blood leukocyte count is present in 50% of cases üStaphylococcus aureus is the aetiological agent in over 50% of cases üLumbar spine is involved in 50% of cases üThe primary lesion is not found in 50% of cases üThe symptoms last over 3 months in 50% of patients ̶ ̶ MUDr. Roman Stebel, Ph.D., MUDr. Jan Kocanda stebel.roman@fnbrno.cz kocanda.jan@fnbrno.cz Adobe Systems 61