1 00:00:07,200 --> 00:00:08,100 Sara Dong: Hi everyone. 2 00:00:08,105 --> 00:00:12,829 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:13,229 --> 00:00:18,540 We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management. 4 00:00:19,050 --> 00:00:21,810 I'm Sara Dong, your host and a Med-Peds ID fellow. 5 00:00:22,200 --> 00:00:28,439 Here on Febrile, we use patient cases and chat with ID discussants to learn more about high yield ID topics. 6 00:00:28,560 --> 00:00:34,980 And I can't believe it, but we'll take any excuse to celebrate because this is the 50th episode of Febrile. 7 00:00:35,010 --> 00:00:44,930 Thanks to everyone who listens to the show, to everyone who has supported, created, contributed or joined for prior episodes, and to those who have shared Febrile with a friend. 8 00:00:45,620 --> 00:00:49,320 Today, I am joined by my co-host Emily Niehaus. 9 00:00:49,790 --> 00:00:57,680 Emily completed her medical school training at the Emory University School Medicine followed by Internal Medicine residency at the University of Utah. 10 00:00:58,370 --> 00:01:04,899 Emily was a resident when she created this episode, but since recording, she has now become a brand new ID fellow at Duke University! 11 00:01:05,480 --> 00:01:08,970 As our guest discussant today, we are joined by Laura Certain. 12 00:01:09,420 --> 00:01:21,900 She is an Assistant Professor of Medicine in the Division of Infectious Diseases and an Adjunct Assistant Professor of Orthopedics at the University of Utah and Chief of Infectious Diseases at the Salt Lake City VA Medical Center. 13 00:01:22,080 --> 00:01:33,510 She received her MD and PhD degrees from the University of Washington in Seattle and her Internal Medicine residency and Infectious Disease fellowship training at Massachusetts General Hospital in Boston. 14 00:01:34,214 --> 00:01:48,554 After fellowship, she completed a post-doctoral research fellowship, studying prosthetic joint infections in an animal model, and then moved to Utah in 2017 to focus more on clinical care of humans with orthopedic infections and a little bit less on mice. 15 00:01:48,675 --> 00:02:00,285 She is currently the Vice President of the Muscoloskeletal Infection Society, a national organization of orthopedic surgeons, infectious disease physicians, and microbiologists with interest in orthopedic infections. 16 00:02:01,200 --> 00:02:03,030 Welcome to the show, guys, how are you doing? 17 00:02:03,030 --> 00:02:03,810 Laura Certain: Doing great. 18 00:02:03,810 --> 00:02:04,800 Thanks for having us. 19 00:02:05,170 --> 00:02:05,660 Emily Niehaus: Hi, Sara. 20 00:02:05,660 --> 00:02:06,330 Doing really well. 21 00:02:07,335 --> 00:02:07,755 Sara Dong: Great. 22 00:02:07,815 --> 00:02:12,405 Before we jump into the case, we always ask about a little piece of culture. 23 00:02:12,795 --> 00:02:16,005 Uh, are you guys willing to share something that you have enjoyed recently? 24 00:02:16,065 --> 00:02:16,395 Laura Certain: Sure. 25 00:02:16,454 --> 00:02:19,785 So, and just so people can get to know our voices. 26 00:02:19,785 --> 00:02:20,355 I'm Dr. 27 00:02:20,355 --> 00:02:22,545 Laura Certain, I'll be the discussant for this case. 28 00:02:22,545 --> 00:02:25,945 And the other voice you're hearing is, uh, Emily Niehaus. 29 00:02:26,265 --> 00:02:30,255 So I love to read, um, as a way to escape. 30 00:02:30,615 --> 00:02:36,565 Uh, and one of the best books I've read recently is, uh, The Lincoln Highway by Amor Towles. 31 00:02:37,024 --> 00:02:37,935 Highly recommend it. 32 00:02:38,205 --> 00:02:42,705 I also recommend The Gentleman in Moscow, which he also wrote. 33 00:02:43,425 --> 00:02:44,235 Sara Dong: What about you, Emily? 34 00:02:44,235 --> 00:02:44,745 Emily Niehaus: Okay, cool. 35 00:02:45,105 --> 00:02:59,325 Um, I am gonna recommend a piece of culture, I don't know how high quality it is, but the TV show, um, Inventing Anna, um, which is highly entertaining. 36 00:02:59,325 --> 00:03:00,975 And, um, I feel. 37 00:03:01,515 --> 00:03:04,005 Kind of a, uh, based on a true story. 38 00:03:04,005 --> 00:03:07,485 I don't know how realistic, but a lot of intrigue. 39 00:03:07,995 --> 00:03:08,385 Sara Dong: Yeah. 40 00:03:08,445 --> 00:03:19,275 It's a, uh, one of those stories that it just seems crazy that it ever happened, even even if they made up some of it, it, it feels, um, a little unbelievable. 41 00:03:19,785 --> 00:03:20,205 Emily Niehaus: mm-hmm 42 00:03:21,120 --> 00:03:21,660 . Sara Dong: All right. 43 00:03:21,750 --> 00:03:24,600 Well, I'll hand it over to you, Emily to get us started. 44 00:03:24,810 --> 00:03:25,500 Emily Niehaus: Okay. 45 00:03:25,500 --> 00:03:28,140 So we're gonna just dive right into our case. 46 00:03:28,470 --> 00:03:46,109 We have a 65 year old male who has a history of diabetes, uh, CKD, BPH, osteoarthritis, and then had a recent hospitalization for COVID who presents to the emergency department for one month of low back pain and three days of fever. 47 00:03:46,410 --> 00:03:49,024 And that was documented up to 101 at home. 48 00:03:50,234 --> 00:03:59,805 He's had some mild intermittent chronic back pain for many years, but four weeks ago, this became persistent and it's progressively worsened since that time. 49 00:04:00,495 --> 00:04:07,815 He doesn't describe any lower extremity weakness, numbness, saddle paraesthesia, or radiating pain down his legs. 50 00:04:08,234 --> 00:04:14,415 He has some chronic issues with nocturia and sensation of incomplete bladder empty. 51 00:04:14,805 --> 00:04:19,635 But no new urinary or bowel incontinence and no recent pain or burning with urination. 52 00:04:20,084 --> 00:04:25,155 He denies chills, uh, night sweats, lethargy, nausea, or weight loss. 53 00:04:25,365 --> 00:04:28,215 And his review systems is otherwise negative. 54 00:04:28,635 --> 00:04:34,235 So on his exam, uh, he has a temperature of 38.1. 55 00:04:34,855 --> 00:04:42,405 Blood pressure of 142/82, and his heart rate's 94 and he's saturating, uh, 96% on room. 56 00:04:43,320 --> 00:04:56,550 Complete exam is notable for, uh, spinal tenderness to palpation over the upper lumbar spine and range of motion on both extension and flexion was limited, mostly due to discomfort. 57 00:04:57,360 --> 00:05:03,690 He had normal sensation to light touch over bilateral lower extremities and straight leg tests were negative as well. 58 00:05:04,860 --> 00:05:09,830 And his notable workup in labs showed a white count of 12.2. 59 00:05:10,405 --> 00:05:20,805 A hemoglobin of 10.5 and platelets of 420 and a creatinine of 2.5 with a BUN of 45, which is around his most recent baseline. 60 00:05:21,765 --> 00:05:35,730 And his inflammatory markers, he had an ESR of 45, uh, CRP of 12, uh, imaging that he had initially, um, a chest x-ray with no acute cardiopulmonary process demonstrated. 61 00:05:35,730 --> 00:05:39,810 And then an MRI of his lumbar spine was obtained in the emergency department as well. 62 00:05:40,320 --> 00:05:48,780 And this showed marrow edema and enhancement within the L2 and L3 vertebral bodies with no notable loss of, um, body height. 63 00:05:49,469 --> 00:05:54,300 And he had abnormal signal and enhancement throughout the L2-L3 disc space. 64 00:05:54,870 --> 00:06:03,030 He had no epidural fluid collection and, um, he'd also had edema in enhancement within the paraspinous musculature. 65 00:06:04,470 --> 00:06:13,620 So at this point, we are the infectious disease team and called by the primary team who's admitting this patient due to concern for infectious process. 66 00:06:14,100 --> 00:06:23,330 Um, so the first question is how does this presentation compare to the usual presentation you might expect for discitis, um, or osteomylitis. 67 00:06:24,315 --> 00:06:24,615 Laura Certain: All right. 68 00:06:24,615 --> 00:06:26,595 Thank you for that presentation. 69 00:06:26,865 --> 00:06:34,815 And I would say this is probably a fairly common scenario that all ID fellows have been called about probably within their first week of ID fellowship. 70 00:06:35,295 --> 00:06:45,660 um, and I'd say, honestly, the thing that makes this case a little bit different, this presentation, a little different, or, um, A bit atypical is actually the fever. 71 00:06:45,930 --> 00:06:49,350 So fever is, can be present in vertebral osteo. 72 00:06:49,500 --> 00:06:53,490 Um, but it is not always, it's only maybe half the time that you'll get a fever. 73 00:06:53,490 --> 00:07:04,440 So it's important to remember that if a, let's say this patient presented with just the back pain, like everything else is exactly the same, but no fever, you would still be worried about, um, vertebral osteo. 74 00:07:04,440 --> 00:07:15,555 So it's important to remember that a patient was sort of new onset back pain, that's persistent or steadily worsening over the course of weeks, certainly warrants further workup. 75 00:07:15,585 --> 00:07:19,995 And usually that workup involves, um, uh, spinal MRI. 76 00:07:20,000 --> 00:07:27,344 Sometimes people will start with x-rays, but really, if you're worried about vertebral osteo, then a spinal MRI is the imaging modality of choice. 77 00:07:27,914 --> 00:07:38,670 We often also get, um, the inflammatory markers, so sed rate (ESR) and CRP, um, they are fairly sensitive, but not that specific obviously. 78 00:07:38,880 --> 00:07:45,540 And if it's an infection with kind of a low virulence organism, they may be normal or only mildly elevated. 79 00:07:45,540 --> 00:07:55,600 So again, they can make you sort of more or less worried about a patient , but they almost never tell you what to do for your patient, is how I think about ESR and CRP. 80 00:07:56,010 --> 00:08:00,360 Um, so in this case, I would say it's a typical presentation. 81 00:08:00,390 --> 00:08:07,780 Um, and we can be fairly suspicious that the MRI findings are infectious in etiology. 82 00:08:08,490 --> 00:08:08,940 Emily Niehaus: Great. 83 00:08:09,000 --> 00:08:09,450 Okay. 84 00:08:09,780 --> 00:08:12,210 So we're gonna learn some more about this guy. 85 00:08:12,900 --> 00:08:15,480 So his medical history is in a little more detail. 86 00:08:15,720 --> 00:08:18,960 He has diabetic and hypertensive nephropathy. 87 00:08:19,740 --> 00:08:22,860 And he had a recent progression of his CKD to stage four. 88 00:08:23,220 --> 00:08:28,740 He has diabetes, that's fairly well controlled recently with an A1C of 7.6. 89 00:08:28,740 --> 00:08:31,110 And he is, uh, using insulin to control that. 90 00:08:31,740 --> 00:08:45,270 Uh, he has BPH and he takes tamulosin for that, but has no, um, acute urinary retention issues and osteoarthritis mostly affecting his knees and he takes Tylenol and has intermittent joint injections for that. 91 00:08:46,605 --> 00:08:50,985 Recently, uh, he had a hospitalization for COVID two months ago. 92 00:08:51,435 --> 00:09:04,215 And during this hospital stay, he was treated in the ICU for a few days, requiring high flow nasal cannula, um, did receive a few days of antibiotics and, um, has now fully recovered with no oxygen needs. 93 00:09:04,725 --> 00:09:07,555 He has, uh, no medication allergies. 94 00:09:07,980 --> 00:09:09,870 And, um, his social history. 95 00:09:09,870 --> 00:09:12,540 So he reports that he was born in Mexico. 96 00:09:12,960 --> 00:09:17,400 Um, he worked in construction between the United States and Mexico for the last 20 years. 97 00:09:17,880 --> 00:09:22,020 Um, but then moved to the US full time five years ago, to be closer to his family. 98 00:09:22,530 --> 00:09:28,920 He's lived for extensive periods of time in Northern Mexico, Southern California, Arizona, and Utah. 99 00:09:29,790 --> 00:09:31,920 He has no history of injection drug use. 100 00:09:31,950 --> 00:09:34,320 He drinks about 10 beers a week. 101 00:09:34,725 --> 00:09:36,075 He's a never smoker. 102 00:09:36,645 --> 00:09:45,525 Uh, and he did have periods of homelessness while living in the US in the eighties, but very distantly, um, and no known exposure to a person diagnosed with TB. 103 00:09:46,335 --> 00:09:56,505 For other exposures, he did interestingly live on a ranch with livestock in Mexico for the last several years before coming to the us, um, with some intermittent exposure to the animals. 104 00:09:56,865 --> 00:10:00,725 Um, and he's unsure if he's ever consumed unpasteurized dairy products. 105 00:10:00,935 --> 00:10:20,085 So now that we have all this information, um, my question is what are this patient's important risk factors for vertebral osteomyelitis and how may these risk factors or other components of its medical or social history impact your differential diagnosis for the microbiology of this possible infection? 106 00:10:20,564 --> 00:10:20,955 Laura Certain: All right. 107 00:10:20,955 --> 00:10:25,395 Lots of fun clues in that, uh, further history. 108 00:10:25,814 --> 00:10:41,955 So in general, the pathophysiology of vertebral osteomyelitis is that a transient bacteremia or not so transient bacteremia finds a site of prior damage in the spine and then sets up shop and causes this chronic osteo infection. 109 00:10:42,495 --> 00:10:52,440 So the typical patient, at least that we see in the US is an older person with some sort of preexisting degenerative disease of the spine. 110 00:10:52,440 --> 00:10:55,800 And usually in humans, that's the cervical or lumbar spine. 111 00:10:55,805 --> 00:10:58,800 That's where we typically have, um, wear and tear in our spine. 112 00:10:59,010 --> 00:11:03,450 So those are, that's the most common side of sort of the routine pyogenic vertebral osteo. 113 00:11:04,290 --> 00:11:14,790 . Um, and so you can obviously get direct extension from a surgical site after spine surgery, but in the person with no prior trauma or no prior known intervention than the spine, 114 00:11:14,970 --> 00:11:19,800 usually it's headed to a site of, um, prior, um, wear and tear damage. 115 00:11:20,340 --> 00:11:29,590 So in, and I will say that this patient's, um, chronic medical conditions probably make him sort of on the mild, mildly immune compromised side with his CKD. 116 00:11:29,595 --> 00:11:33,270 And so that may also have put him more at risk for infection. 117 00:11:34,305 --> 00:11:38,355 now Staphylococcal species are by far the most common cause. 118 00:11:38,625 --> 00:11:42,045 Um, but Strep and Gram negatives make up a sizable portion. 119 00:11:42,105 --> 00:11:50,745 And so because of, um, the pathophysiology coming from bacteremia, IV drug use is a significant risk factor though not an issue for this patient. 120 00:11:51,135 --> 00:11:59,795 Um, this patient had a recent hospitalization for COVID, so that probably meant he had some sort of lines put in, IVs probably at some point, maybe for his remdesivir or whatever. 121 00:11:59,795 --> 00:12:03,185 So in theory, he could have had a bacterimia associated with that. 122 00:12:03,545 --> 00:12:08,365 He could have had a superimposed bacterial pneumonia that might have made him transiently bacteremic. 123 00:12:09,005 --> 00:12:16,055 Given his BPH, maybe he had a UTI recently that he just forgot about, or hasn't told us about and had bacteremia from. 124 00:12:17,130 --> 00:12:25,320 So I think any of those things could have led to a transient bacteremia that has now caused for vertebral osteomyelitis. 125 00:12:25,770 --> 00:12:32,730 So in the US, we are normally seeing sort of routine run of the mill bacterial, um, vertebral osteomyelitis. 126 00:12:33,180 --> 00:12:39,275 In other parts of the world, um, Brucella and TB, uh, make up a large proportion of cases. 127 00:12:39,275 --> 00:12:41,584 So it's important to keep those in mind. 128 00:12:41,584 --> 00:12:51,964 And now this patient, for example, he's not sure about his consumption of, uh, unpasteurized dairy products, uh, and has, uh, lived in parts of the world where TB is more common. 129 00:12:52,175 --> 00:12:57,605 So certainly you could consider TB, um, vertebral osteo or Potts disease. 130 00:12:58,200 --> 00:13:05,160 Traditionally that is thought to involve the thoracic vertebrae more often, but obviously TB can do kind of whatever it wants. 131 00:13:05,160 --> 00:13:08,700 So just cuz it's not thoracic doesn't mean that it's not TB. 132 00:13:09,240 --> 00:13:22,950 Of note, I was, um, in preparing for this, uh, podcast, I was looking at studies and there was a study from Turkey, looking at their cases of, um, vertebral osteo and 45% of them were Brucella and 29% were TB. 133 00:13:23,160 --> 00:13:27,320 So just to get, which of course is not at all our experience in the US. 134 00:13:27,500 --> 00:13:27,890 Right. 135 00:13:28,070 --> 00:13:35,600 Um, and I also should note that Brucella, my husband calls it Mediterranean cheese disease because he, uh, helped me study for the boards. 136 00:13:35,600 --> 00:13:40,310 And that's one of the few things he remembers is that Brucella is Mediterranean cheese disease. 137 00:13:40,760 --> 00:13:44,450 um, that and tularemia is aerosolized rabbit disease. 138 00:13:44,750 --> 00:13:52,125 But in any event, um, so, uh, in this patient, Brucella and TB, you know, possible. 139 00:13:52,155 --> 00:13:56,895 Um, so worth considering you could send an interferon gamma release assay. 140 00:13:56,955 --> 00:13:59,535 Granted that is not, that's a test for latent TB. 141 00:13:59,535 --> 00:14:14,895 You should not be using it to diagnose active TB, but actually in that study from Turkey, the, a positive PBD had a sensitivity of 0.66, and specificity of 0.97 for diagnosing TB vertebral osteo, which is better than I would've thought. 142 00:14:15,225 --> 00:14:18,705 So in a population where it's common, maybe it is helpful. 143 00:14:19,260 --> 00:14:26,459 This patient also has risk for endemic fungi, especially Cocci[dioides], um, having spent time in Southern California, Arizona, et cetera. 144 00:14:26,880 --> 00:14:32,100 So that certainly can cause um, vertebral osteo , Cocci can cause bone and joint infections. 145 00:14:32,160 --> 00:14:35,370 Um, but it's pretty darn rare. 146 00:14:35,610 --> 00:14:43,260 So you could consider sending Cocci serologies or looking for other, you know, uh, serum markers of endemic fungi. 147 00:14:43,319 --> 00:14:50,385 But again, most likely this guy is gonna have a routine run of the mill, um, standard bacterial vertebral osteo. 148 00:14:51,255 --> 00:14:51,825 Emily Niehaus: Awesome. 149 00:14:51,975 --> 00:14:53,565 That's great review. 150 00:14:54,165 --> 00:14:57,765 And, um, so let's see what happened to this guy. 151 00:14:57,770 --> 00:15:07,155 So he was admitted, um, to the general medicine service and he did have orthopedics, uh, spine service that was consulted for him in the emergency room. 152 00:15:07,395 --> 00:15:16,575 They didn't recommend surgery at this moment, um, because he had a normal neurologic exam, but they were gonna follow him through his hospital, stay and look for some dynamic change. 153 00:15:17,160 --> 00:15:20,099 When he gets to the floor, he's hemodynamically stable. 154 00:15:20,400 --> 00:15:28,140 And, um, I just wanna start broadly, what workup and treatment would you first recommend, um, for this patient? 155 00:15:28,439 --> 00:15:33,540 Laura Certain: So all patients presenting, uh, with concern for vertebral osteo should get blood cultures. 156 00:15:33,839 --> 00:15:44,430 Because if you get lucky, or I don't know if this is lucky, but if they have a Staph aureus bacteremia, not exactly so lucky for the patient mm-hmm , but it does mean that they don't have to have their spine biopsied, so in that sense, it's lucky. 157 00:15:44,730 --> 00:15:58,860 Cause again, IDSA guidelines would say, um, that if you have positive blood cultures with an organism that is known to cause vertebral osteo such as Staph aureus, or Staph lugdunensis, then you can stop there. 158 00:15:58,860 --> 00:16:07,020 You can just assume that that is the culprit bug and you do not need to pursue further, um, diagnostic workup in terms of identifying the culprit pathogen. 159 00:16:07,440 --> 00:16:10,850 Um, so you definitely would want blood cultures prior to starting antibiotic. 160 00:16:11,850 --> 00:16:16,140 As we discussed above, you might send some other tests depending on risk factors. 161 00:16:16,140 --> 00:16:19,650 So test serum markers for, and serologies for fungal infections. 162 00:16:19,650 --> 00:16:23,640 If you think it might be that again, you can send an interferon gamma release assay, though. 163 00:16:23,640 --> 00:16:36,314 You might get yelled at, by other ID attendings who insist that that is for latent TB testing only, and you should not be sending it in patients where you're considering active TB, but really this person is probably headed for, uh, a bone biopsy. 164 00:16:36,375 --> 00:16:46,425 So probably you're gonna be calling your IR colleagues, uh, to get a sample of the infected tissue to send for culture and path if they can. 165 00:16:46,485 --> 00:16:49,185 Sometimes they don't get a ton of tissue. 166 00:16:49,185 --> 00:16:51,285 So you're sometimes limited by amounts. 167 00:16:51,585 --> 00:17:08,589 Um, obviously if there's abscess, you want them to drain the abscess and in a pinch, maybe you might end up with a surgical biopsy, but almost certainly the first step is a CT guided biopsy and you should be holding antibiotics in a stable patient until you have a microbiologic diagnosis. 168 00:17:09,600 --> 00:17:14,640 That said, I mean, so there's a lot of emphasis on holding antibiotics until you get the biopsy done. 169 00:17:14,910 --> 00:17:21,660 A single dose of vancomycin or whatever is unlikely to actually affect the biopsy results that much. 170 00:17:21,660 --> 00:17:33,300 But don't tell anybody that because no, just tell them they keep holding antibiotics until you've got those tissue samples and potentially until you actually have a diagnosis. 171 00:17:33,765 --> 00:17:36,975 Because the sensitivity of these bone biopsy is not great. 172 00:17:36,975 --> 00:17:42,825 There's a huge range out there in the literature, but maybe 50 50 that you're gonna get your answer from a single biopsy. 173 00:17:43,155 --> 00:17:44,085 And so then. 174 00:17:44,925 --> 00:17:47,595 if that biopsy is negative, right? 175 00:17:47,595 --> 00:17:53,925 Doesn't give you the answer or grows like one colony of Staph epidermidis, and you're like, well, is that real? 176 00:17:53,925 --> 00:17:55,215 Is that not real? 177 00:17:55,725 --> 00:17:59,475 You're left, basically trying to convince people to do it again. 178 00:18:00,315 --> 00:18:06,825 um, or convincing the surgeons to do an open biopsy or just treating empirically. 179 00:18:07,709 --> 00:18:14,909 So I think there are studies that show increased yield with a second needle biopsy, um, or an open biopsy. 180 00:18:14,909 --> 00:18:18,719 I feel like in practice, usually they get their one biopsy, 181 00:18:18,719 --> 00:18:25,320 as soon as they're done, they get started on empiric antibiotics, and sometimes they'll get the answer and sometimes they just get treated empirically. 182 00:18:25,815 --> 00:18:26,115 Emily Niehaus: Yeah. 183 00:18:26,115 --> 00:18:30,075 So you, that was exactly where this patient was heading. 184 00:18:30,610 --> 00:18:33,915 he, um, he ended up getting blood cultures. 185 00:18:33,915 --> 00:18:37,995 He did get a dose of a vancomycin and ceftriaxone in the emergency room. 186 00:18:38,325 --> 00:18:41,245 And then, um, they were held, cultures were awaited. 187 00:18:41,265 --> 00:18:42,225 He was stable. 188 00:18:42,585 --> 00:18:46,155 And by day three, he had no growth on his blood cultures. 189 00:18:46,455 --> 00:18:50,235 So, um, he underwent a CT guided biopsy. 190 00:18:50,555 --> 00:18:59,975 The cultures of that eventually grew methicillin resistant Staphylococcus aureus, and his pathology was also consistent with acute osteomyelitis. 191 00:19:00,584 --> 00:19:12,254 So at that point, his antibiotics, he was, uh, started on vancomycin and now the ortho team signed off because there's no plan for surgical management, just medical management. 192 00:19:12,615 --> 00:19:20,465 So the question is what is our medical management and how should we approach this, um, duration of antibiotics and monitoring going forward? 193 00:19:21,080 --> 00:19:27,350 Laura Certain: So the typical duration for vertebral osteo is six weeks of antibiotics. 194 00:19:27,410 --> 00:19:32,000 Um, uh, there was a randomized clinical trial, uh, published in the Lancet in 2015. 195 00:19:32,270 --> 00:19:38,330 Um, showing that six weeks was non-inferior to 12 weeks of antibiotics for pyogenic vertebral osteo. 196 00:19:38,335 --> 00:19:46,510 So that has made six weeks pretty much the standard course, whether to treat with PO or IV antibiotics. 197 00:19:46,510 --> 00:19:57,910 I feel like in the post OVIVA era, you can switch to PO whenever you want, if you have antibiotic that has good oral bioavailability, that will treat the infection. 198 00:19:58,000 --> 00:20:05,560 Of note in that Lancet paper looking at duration of treatment, the most common regimen was actually a quinolone plus rifampin so not IV antibiotics. 199 00:20:06,100 --> 00:20:11,530 In this patient, um, his kidney disease may make it a little bit challenging to treat, right. 200 00:20:11,534 --> 00:20:17,640 So vancomycin is fine, but may be difficult to monitor. 201 00:20:17,640 --> 00:20:21,630 You're gonna wanna be real careful that he doesn't get supratherapeutic on his vanco. 202 00:20:21,960 --> 00:20:24,600 You could consider daptomycin instead. 203 00:20:24,690 --> 00:20:27,930 High dose Bactrim (trimethoprim-sulfamethaxazole) I'd probably avoid in this patient, 204 00:20:27,930 --> 00:20:32,400 that seems like it could be challenging, uh, in somebody with renal disease. 205 00:20:32,460 --> 00:20:41,350 If his isolate was susceptible and his drug drug interactions didn't preclude it, levofloxacin + rifampin could be an option for him as well. 206 00:20:41,740 --> 00:20:47,860 Linezolid is pretty hard to tolerate for six weeks and tedizolid is pretty hard to get. 207 00:20:48,669 --> 00:20:55,930 So I think for him, he is probably likely to be discharged on vancomycin and then monitored thereafter. 208 00:20:56,370 --> 00:21:04,050 Now a lot of people will trend, uh, sed rate and C R P uh, to try to give, to see who's responding and how things are going. 209 00:21:04,470 --> 00:21:11,879 And they can give you some sense of who's responding to therapy, but it's not clear what to do if they don't respond. 210 00:21:12,090 --> 00:21:20,370 So there's data that like, if they don't fall, those are patients who are likely to quote unquote, fail therapy or have a recurrence of infection after you stop. 211 00:21:20,730 --> 00:21:29,015 But it's not clear that treating them for longer is gonna solve the problem or whether they just need surgical debridement for source control. 212 00:21:29,285 --> 00:21:32,675 So we, we look at them, but again, they can make you more or less worried. 213 00:21:32,825 --> 00:21:34,085 They never tell you what to do. 214 00:21:36,065 --> 00:21:43,060 I think, and in speaking of recurrence, I mean, you do wanna make sure that the patient didn't have an undrained abscess, right? 215 00:21:43,060 --> 00:21:52,540 That's something that might mean make them more likely to fail medical management only if they had an undrained abscess, um, also renal disease and diabetes can make patients more likely to fail. 216 00:21:52,540 --> 00:21:57,660 So this and the fact that this patient has MRSA, all of that is a little bit worrisome in terms of his overall prognosis. 217 00:21:58,600 --> 00:22:04,430 So I think in general, for this patient, you would probably put 'em on vanco[mycin] or dapto[mycin],. 218 00:22:04,610 --> 00:22:08,450 Check blood work weekly and see how he responds clinically. 219 00:22:08,990 --> 00:22:11,060 We typically do not get repeat imaging. 220 00:22:11,060 --> 00:22:18,890 A lot of patients will ask like, well, shouldn't I get an MRI at the end of my therapy to make sure that I'm all better and the answer is no, you should not do that. 221 00:22:18,950 --> 00:22:24,830 Uh, especially if the patient is feeling better, if their pain is getting better, their inflammatory markers are coming down, et cetera. 222 00:22:25,250 --> 00:22:28,610 Um, patients get better long before their imaging does. 223 00:22:28,640 --> 00:22:36,735 And so the imaging will likely, still be abnormal at the end of those six weeks, so if everything else is pointing in a good direction, you just stop therapy. 224 00:22:36,735 --> 00:22:38,235 You do not get repeat imaging. 225 00:22:38,504 --> 00:22:44,385 Now, if you are worried about someone like their inflammatory markers aren't coming down, they're having persistent or worsening pain. 226 00:22:45,044 --> 00:22:51,690 that's a time when I do get repeat imaging, because maybe they have developed an abscess, maybe they've developed a drainable fluid collection. 227 00:22:52,020 --> 00:22:59,580 Uh, so that would be important to know because that you're not gonna solve that problem with antibiotics likely, you need your surgical colleagues to intervene. 228 00:23:00,060 --> 00:23:00,630 Emily Niehaus: Okay. 229 00:23:00,960 --> 00:23:09,630 Well, so our patient, um, he did, um, he was discharged on three weeks of vancomycin followed, um, with labs. 230 00:23:10,200 --> 00:23:12,720 And, uh, outpatient follow up with ID. 231 00:23:13,020 --> 00:23:18,180 Um, he was actually transitioned to doxycycline after three weeks, um, to complete his course. 232 00:23:18,185 --> 00:23:20,430 And initially, uh, his symptoms had improved. 233 00:23:20,435 --> 00:23:24,450 He was feeling good at that first follow appointment around like two week mark. 234 00:23:24,450 --> 00:23:27,060 And then at six week follow up appointment. 235 00:23:27,465 --> 00:23:35,445 Um, he described, uh, new radiating lightning, like pain down his left leg, um, and his back pain just wasn't better. 236 00:23:35,535 --> 00:23:41,105 He didn't have any fevers or chills that he was describing and his vital signs were normal in clinic. 237 00:23:41,865 --> 00:23:45,615 His exam was similar to when he was first evaluated. 238 00:23:45,765 --> 00:23:47,325 It's like spinal tenderness. 239 00:23:47,595 --> 00:23:54,165 Um, and then his inflammatory markers kind of throughout his course did not, um, change drastically. 240 00:23:54,165 --> 00:23:59,985 And actually at this six week point, his ESR is 40 and that was 45 initially. 241 00:23:59,985 --> 00:24:01,335 And his CRP is 15. 242 00:24:01,605 --> 00:24:03,635 So that was 12 initially. 243 00:24:04,020 --> 00:24:24,899 And then now, because of concern for an unresolved infection, a repeat MRI was obtained and that showed progressive end plate destruction of L2-L4 and a new epidural fluid collection, um, with a phlegmon or abscess at the level of two to three, and this was contributing to spinal canal stenosis.. 244 00:24:25,649 --> 00:24:35,580 So at this point, orthopedic surgery was called and reviewed the imaging and he ended up being admitted to the hospital for a planned decompression infusion of his spine. 245 00:24:36,480 --> 00:24:43,889 Um, the surgery was performed and then he had operative cultures of both the abscess and the bone, again, that grew MRSA. 246 00:24:44,429 --> 00:24:47,399 And he was started back on vancomycin after the surgery. 247 00:24:47,760 --> 00:24:50,280 Um, but didn't receive any antibiotics beforehand. 248 00:24:50,625 --> 00:24:54,915 So now this patient has had, uh, initial failed course of treatment. 249 00:24:55,215 --> 00:24:57,435 Um, and now has hardware implanted. 250 00:24:57,645 --> 00:25:02,745 So how should we address ongoing as a treatment failure at this point? 251 00:25:03,240 --> 00:25:03,420 Laura Certain: Yeah. 252 00:25:03,420 --> 00:25:06,990 So this is unfortunately a not uncommon scenario. 253 00:25:06,990 --> 00:25:15,990 You sort of treat the person appropriately at the get go, but you know, Staph are devious and sometimes they just win despite the antibiotics. 254 00:25:16,110 --> 00:25:34,669 Um, and so now he's had a surgical debridement, so that's good that probably gonna help with his source control, but they've also stuck a bunch of new hardware directly into that infected space, which always makes us worried, um, about, uh, creation of biofilm on that on the hardware, making it harder to, um, eradicate the infection. 255 00:25:35,540 --> 00:25:40,159 So this patient is looking at another prolonged course of antibiotics. 256 00:25:40,340 --> 00:25:58,350 Exactly how long is not clear, but there was, um, a retrospective study of patients who had had hardware placed into an infected space, who had pyogenic vertebral osteomyelitis, and needed hardware placed for stabilization of their infected spine. 257 00:25:58,740 --> 00:26:02,250 And in that study, longer was better. 258 00:26:02,310 --> 00:26:11,130 So there were fewer recurrences in the patients who got more than eight or who got at least eight weeks of antibiotics after their surgery. 259 00:26:11,460 --> 00:26:14,890 So I usually do at least eight weeks in these patients. 260 00:26:16,010 --> 00:26:28,125 whether or not to add rifampin often comes up and I will say, I have also surveyed my ortho ID colleagues to ask them whether or not they would add rifampin in situations such as these and some do. 261 00:26:28,125 --> 00:26:29,145 And some do not. 262 00:26:29,355 --> 00:26:50,840 I think most feel that if there aren't contraindications to it, like they're not on Coumadin or some other, um, difficult to manage drug, drug interactions, and they tolerate the rifampin, it's probably worth adding it because it has well it's controversial and they're definitely the pro rifampin and the anti rifampin teams in ID. 263 00:26:51,440 --> 00:27:01,430 I think there is data out there to suggest that it does help with biofilm related infections and therefore if your patient can tolerate it and there are no contraindications, it's reasonable to try. 264 00:27:01,879 --> 00:27:05,330 I do not uniformly add rifampin in this scenario. 265 00:27:05,360 --> 00:27:07,850 Um, but I do try to treat for at least eight weeks. 266 00:27:08,655 --> 00:27:08,895 Emily Niehaus: Good. 267 00:27:08,895 --> 00:27:09,075 Yeah. 268 00:27:09,075 --> 00:27:15,345 So we'll just kind of wrap things up with this case, um, to kind of give the ending result here. 269 00:27:15,345 --> 00:27:17,595 Our patient was treated with eight weeks of antibiotics. 270 00:27:17,595 --> 00:27:28,455 Rifampin was added, so he was able to tolerate that and he completed his antibiotics, had no further infectious symptoms, his pain improved, and his inflammatory markers also improved. 271 00:27:28,785 --> 00:27:30,025 So overall good results. 272 00:27:30,600 --> 00:27:34,020 So that's kind a conclusion to our first case. 273 00:27:34,020 --> 00:27:45,600 I just kind of wanted to explore additional like hypothetical alternative situation that's a very common reason for consult as well for, or, um, spine infections. 274 00:27:45,990 --> 00:28:07,245 Um, so we kind of discussed someone who had surgery and hardware implanted for a primary infectious process, but wanna discuss the alternative situation where someone had hardware implanted for a primary orthopedic indication and then subsequently developed infectious symptoms at that site. 275 00:28:07,695 --> 00:28:11,835 So, how would you approach that scenario differently than what we've already discussed? 276 00:28:12,465 --> 00:28:13,005 Laura Certain: Thank you. 277 00:28:13,005 --> 00:28:13,365 Yes. 278 00:28:13,365 --> 00:28:17,505 That's a very common and also very challenging situation. 279 00:28:17,505 --> 00:28:24,015 And one of the reasons it's challenging is cuz there's actually very little data to tell us how best to treat these patients. 280 00:28:24,015 --> 00:28:47,585 Like I keep looking and I feel like maybe I'm U I must be using the wrong search terms or missing something because I keep trying like, surely someone has looked at this in some sort of thorough way, but no, I mean, as far as I can show the evidence out there is mainly, um, retrospective data from single centers and everybody's defined things a little bit differently and what they consider early infection versus late infections, superficial versus deep etc 281 00:28:47,875 --> 00:28:54,804 so it's really challenging because we don't have any great data to guide our management of these patients. 282 00:28:55,135 --> 00:29:04,230 Now it is, um, true that some people will distinguish between, um, a superficial infection versus a deep infection. 283 00:29:04,409 --> 00:29:14,460 So superficial meaning that it was sort of above the fascia thought to be mainly just a skin and, and superficial soft tissue infection after surgery. 284 00:29:14,790 --> 00:29:19,410 And those are usually treated with a relatively short course of antibiotics. 285 00:29:19,410 --> 00:29:23,520 But what we're usually consulted on is when there's concern for deeper infections. 286 00:29:23,520 --> 00:29:43,570 So infection of the surgical site that goes below the fascia, where they're concerned that it's an involving the bone and, or the hardware, or at least was really, really close to the bone and the hardware . And so they were worried that, uh, that bacteria are gonna, um, weasel their way in and like again, cause a concern for a chronic infection around the hardware in the bone. 287 00:29:44,140 --> 00:29:49,900 So that's usually what we're talking about is these deep surgical site infections and usually early onset ones. 288 00:29:49,900 --> 00:29:52,900 So usually ones that are presenting within the first three months. 289 00:29:52,960 --> 00:29:56,410 Um, and usually even sooner than that after their initial fixation surgery. 290 00:29:57,275 --> 00:30:04,955 Obviously, yes, people could have an infection at the site that would present further out from surgery, but that is much less common. 291 00:30:04,955 --> 00:30:18,485 So usually what we're talking about is a relatively early, um, surgical site infection after spinal fusion surgery, where there's concern that the infection has progressed to involve the deep space and therefore could be involving the bone and, or the hardware. 292 00:30:19,185 --> 00:30:27,015 so in terms of treating them, obviously the surgeons typically take 'em back to the, or open everything up, wash it out as best they can, take samples. 293 00:30:27,015 --> 00:30:29,355 And that helps us know how to treat these patients. 294 00:30:29,355 --> 00:30:30,435 Cuz we'll know the bug. 295 00:30:31,409 --> 00:30:41,699 In terms of duration, uh, that is anyone's guess . And again, on these, uh, retrospective studies, the range of treatment was quite broad. 296 00:30:42,030 --> 00:30:52,590 Um, some people will treat for six weeks, some people three months, some people keep patients on oral suppressive therapy for six months to a year, or maybe even indefinitely. 297 00:30:53,370 --> 00:31:25,065 And I think for me, the decision on how long to treat people often is the shared decision making with the patient and the surgeon, because I don't know when every last bacteria has been eradicated from their spine, there is no test that's gonna tell me that they are cured and some fraction, it may be a small fraction, but some fraction of these patients, especially if they had a Staph infection may relapse after we stop therapy. 298 00:31:25,679 --> 00:31:35,969 . And so I have to have that conversation with the patient and the surgeon about, well, if we stop antibiotics and you have a relapse, what is that gonna mean for you? 299 00:31:35,969 --> 00:31:37,830 What surgery are you gonna need to have? 300 00:31:37,860 --> 00:31:39,689 And what would that mean for your life? 301 00:31:39,899 --> 00:31:50,594 So we'll often have a shared discussion about what the surgery would mean for them and how much they hate being on the antibiotics that they're on. 302 00:31:50,594 --> 00:31:53,445 And that will help guide, uh, our management. 303 00:31:53,685 --> 00:31:56,655 I also take into consideration the age of the patient. 304 00:31:56,864 --> 00:32:26,115 So for example, if I have a otherwise healthy 35 year old who had spine fixation surgery, and it was a relatively small, um, section of their spine, Not a cervical to pelvis fixation, for example, but like a healthy person who had, you know, maybe three lumbar vertebrae fused, got an early postop MSSA infection got washed out and I put them on levofloxacin and rifampin for three months. 305 00:32:26,745 --> 00:32:29,895 And at the end of that time, they're feeling great. 306 00:32:29,925 --> 00:32:33,165 Their inflammatory markers have been normal for eight weeks. 307 00:32:33,195 --> 00:32:35,775 Um, and they've had no issues then. 308 00:32:35,835 --> 00:32:39,945 Um, I usually stop and see how they do. 309 00:32:40,905 --> 00:32:57,405 In someone who was slower to respond to therapy or in whom I am more worried about what another surgery would mean for them medically, like they're more frail, they're elderly, et cetera, or their spine surgery was much more extensive to begin with. 310 00:32:57,945 --> 00:33:01,725 I am more likely to keep them on long term oral antibiotics. 311 00:33:02,295 --> 00:33:18,950 I also will sometimes keep patients on oral antibiotics or some kind of suppressive therapy until their spine has fused so that, um, if the infection were to recur, the hardware could be taken out, but spinal fusion can take six to 12 months from the time of their initial surgery. 312 00:33:18,950 --> 00:33:21,860 So that's not a particularly short timeframe. 313 00:33:22,340 --> 00:33:22,580 Sara Dong: Yeah. 314 00:33:23,150 --> 00:33:23,240 Yeah. 315 00:33:23,240 --> 00:33:32,210 I think that's so important, weighing, like you said, the surgery versus I love how you framed it as how much they hate being on antibiotics. 316 00:33:32,360 --> 00:33:35,690 I was thinking, as you were saying that it's totally true. 317 00:33:36,344 --> 00:33:46,915 I've seen patients on the adult side and we have those conversations, but also when we have hardware infections in younger patients, it's obviously not feasible to have them on antibiotics forever. 318 00:33:48,225 --> 00:33:52,635 um, and it's, it's like figuring out what is that appropriate timeframe. 319 00:33:52,635 --> 00:33:55,784 And every time it just kind of feels like you're making it up still. 320 00:33:56,175 --> 00:34:02,235 And maybe one day we'll feel a little bit more confident, but I'll think of a different way to say it other than we're making it up. 321 00:34:02,235 --> 00:34:04,274 We're making our best guess. 322 00:34:04,635 --> 00:34:06,854 But in many ways, that's, that's kind of what we're doing. 323 00:34:07,514 --> 00:34:08,025 Laura Certain: Yeah. 324 00:34:08,025 --> 00:34:19,530 And I will say obviously the duration of therapy, both for hardware involvement or native vertebral osteo would be different if they did have TB or a fungal infection. 325 00:34:19,530 --> 00:34:24,750 Obviously we've been talking in this episode mainly about, um, run of the mill bacterial infections. 326 00:34:24,930 --> 00:34:33,480 Obviously you might consider much longer durations if it were a fungal infection or mycobacterial infection, those are sort of a different beast. 327 00:34:33,990 --> 00:34:42,030 I think what I usually say to patients is some variation on, I have no way of knowing whether or not you're cured. 328 00:34:43,365 --> 00:34:48,285 If we stop antibiotics and your infection comes back, you will need more surgery. 329 00:34:50,009 --> 00:34:50,940 what do you wanna do? 330 00:34:51,900 --> 00:34:52,080 yeah. 331 00:34:52,889 --> 00:35:01,380 If I have the data to tell them what I think the chances are of their infection coming back, I will share that with them. 332 00:35:01,384 --> 00:35:09,569 So for prosthetic joint infections, for example, we can often say like, well, typically people treated with a two stage exchange have a recurrence risks of X or whatever. 333 00:35:09,900 --> 00:35:13,200 Unfortunately, we usually don't really have that data. 334 00:35:13,230 --> 00:35:18,090 And so I'm kind of taking my guess of what I think their chances are. 335 00:35:18,930 --> 00:35:23,955 Sara Dong: well, you guys tackled a very big topic and I will leave it open one more time. 336 00:35:23,955 --> 00:35:31,455 Is there anything else that you think people should know when we're thinking about spinal infections, osteomyelitis or anything that we've missed along the way? 337 00:35:31,815 --> 00:35:33,945 Laura Certain: I think we definitely hit the highlights. 338 00:35:34,275 --> 00:35:41,715 I think, uh, this like all, um, orthopedic infections, which are my jam, uh, are. 339 00:35:42,065 --> 00:35:45,305 It's important to have conversations with your surgical colleagues. 340 00:35:45,365 --> 00:36:15,710 So whether that's neurosurgery or ortho spine, um, especially in a patient who is sort of failing medical therapy or about whom you are worried will be failing medical therapy, it's worth having that, um, conversation, um, with the surgeon because often, you know, the only real indication for surgery or one of the first indications for surgery is that they are having neurologic changes or severe, um, compression of the spinal cord, but sometimes you need surgery for source control. 341 00:36:16,170 --> 00:36:30,360 Sometimes it's important to have that conversation with the surgeons and explain why you're worried that antibiotics alone are not gonna be adequate in this patient or why you're worried that antibiotics alone are not working in this particular patient. 342 00:36:30,960 --> 00:36:31,970 Sara Dong: Yeah, that's a great point. 343 00:36:32,520 --> 00:36:33,000 All right. 344 00:36:33,000 --> 00:36:34,830 Well, thank you guys so much for coming. 345 00:36:34,830 --> 00:36:38,580 You're welcome back anytime, we need to cover a lot more ortho ID topics. 346 00:36:38,580 --> 00:36:39,600 We'll get there slowly. 347 00:36:40,339 --> 00:36:45,930 Laura Certain: Sara would be delighted anytime to talk about ortho ID topics or whatever general ID topics. 348 00:36:46,190 --> 00:36:47,730 I be happy to be back. 349 00:36:47,730 --> 00:36:48,270 It's been fun. 350 00:36:48,750 --> 00:36:49,260 Emily Niehaus: Thanks Sarah. 351 00:36:49,840 --> 00:36:51,370 Sara Dong: Thanks for tuning in everyone. 352 00:36:51,550 --> 00:37:02,440 Don't forget to check out the website, febrilepodcast.com to find the Consult Notes, which are written complements of the show with links to references, our library of ID infographics, and a link to our merch store. 353 00:37:02,980 --> 00:37:07,430 Please reach out if you have any suggestions for future shows or wanna be more involved with Febrile. 354 00:37:07,840 --> 00:37:08,650 Thanks for listening. 355 00:37:08,710 --> 00:37:10,480 Stay safe and I'll see you next time.