• Conservative versus early surgical treatment in the management of pyogenic spondylodiscitis: a systematic review and meta-analysis
• Massive empyema due to <em>Lactococcus garvieae</em>
• Pharmacokinetic and pharmacodynamic considerations for optimizing antimicrobial therapy used to treat bone and joint infections: an evidence-based algorithmic approach
• Surgical treatment of <em>Candida albicans</em> spondylodiscitis
• Carbapenem-Resistant <em>Pseudomonas aeruginosa</em> Spondylodiscitis Treated with Ceftazidime-Avibactam: A Case Report with Literature Review
• Unveiling the Culprit: Candida-Induced Spondylodiscitis Following SARS-CoV-2 Infection
• Posterior Fixation Without Debridement for Vertebral Body Osteomyelitis and Discitis: A 10-Year Retrospective Review
• The Efficacy of Daily Local Antibiotic Lavage via an Epidural Suction-Irrigation Drainage Technique in Spondylodiscitis and Isolated Spinal Epidural Empyema: A 20-Year Experience of a Single Spine Center

Antibiotic therapy is a pillar of treatment for spondylodiscitis and should be a part of the treatment in all cases. Neurologic deficits, sepsis, intraspinal empyema, the failure of conservative treatment, and spinal instability are all indications for surgical treatment ¹⁾.

Randomized trials to guide the selection of the appropriate route, duration, or agent for antibiotic therapy are lacking. Practice is based on retrospective case series, expert opinion, and data extrapolated from animal and laboratory data.

The choice of antibiotics for the treatment of spondylodiscitis depends on several factors, including the suspected or identified causative microorganism, the severity of the infection, and individual patient factors such as allergies and underlying medical conditions. Empirical antibiotic therapy may be initiated before the exact microorganism is identified based on clinical presentation and risk factors. However, once the causative organism is identified through cultures, antibiotic therapy can be adjusted accordingly. Commonly implicated bacteria in pyogenic spondylodiscitis include Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus or MRSA), Streptococcus species, and Escherichia coli.

Here are some antibiotic options commonly used for the treatment of spondylodiscitis:

Empirical Antibiotics: These antibiotics may be started before the specific microorganism is identified. Common choices include:

Intravenous (IV) antibiotics such as ceftriaxone or cefotaxime plus MRSA coverage with vancomycin or daptomycin. Broad-spectrum antibiotics like piperacillin-tazobactam or meropenem in critically ill patients with risk factors for multidrug-resistant organisms. Specific Antibiotics: Once the causative organism is identified, the antibiotics can be tailored to target that particular microorganism. Antibiotics often used for specific bacteria include:

For Staphylococcus aureus, including MRSA: Vancomycin, daptomycin, or linezolid. For Streptococcus species: Penicillin or ceftriaxone. For Escherichia coli and other Gram-negative bacteria: Ceftriaxone, cefotaxime, or fluoroquinolones.

The duration of antibiotic therapy typically ranges from 6 to 12 weeks or longer, depending on the severity of the infection, the response to treatment, and the presence of complications. Prolonged treatment is often necessary to ensure complete eradication of the infection and to prevent relapse.

The appropriate duration of parenteral antibiotic treatment in patients with pyogenic spondylodiscitis after surgical intervention could be guided by the risk factors. The duration of postoperative intravenous antibiotic therapy could be reduced to 3 weeks for patients without positive blood culture or abscess formation ²⁾

Intravenous to Oral Transition: In some cases, patients may be transitioned from intravenous to oral antibiotics once they show clinical improvement and are stable. This transition is based on the patient’s clinical response and the recommendations of the healthcare team.

Monitoring: Close monitoring of the patient’s clinical progress, laboratory markers of infection (such as C-reactive protein and erythrocyte sedimentation rate), and imaging studies is essential to assess treatment efficacy and identify any complications.

It’s important for patients to complete the full course of antibiotics as prescribed to prevent relapse and the development of antibiotic resistance.

A nationwide survey of empiric antibiotic treatment for pyogenic spondylodiscitis revealed a large heterogeneity in the standard of care. A combination of a broad-spectrum-β-lactam antibiotic with an additional glycopeptide antibiotic may be justified ³⁾

Empirical broad-spectrum antibiotic therapy is linked to increased rates of complications such as Clostridium difficile-associated diarrhea and higher healthcare costs ⁴⁾, and should be reserved for patients presenting with severe sepsis once blood cultures have been taken.

Question 1: Which of the following is NOT an indication for surgical treatment in spondylodiscitis?

A) Neurologic deficits B) Sepsis C) Intraspinal empyema D) Positive blood culture

Question 2: Why might empirical antibiotic therapy be initiated before the exact microorganism is identified in spondylodiscitis?

A) To prevent antibiotic resistance B) To reduce the duration of antibiotic treatment C) To avoid potential side effects of antibiotics D) To provide immediate treatment while awaiting culture results

Question 3: Which of the following is a commonly implicated bacterium in pyogenic spondylodiscitis?

A) Candida albicans B) Escherichia coli C) Mycobacterium tuberculosis D) Streptococcus pneumoniae

Question 4: What is the typical duration of antibiotic therapy for spondylodiscitis?

A) 1-2 weeks B) 2-4 weeks C) 4-6 weeks D) 6-12 weeks or longer

Question 5: Under what circumstances can intravenous antibiotic therapy be reduced to 3 weeks after surgical intervention in spondylodiscitis?

A) Positive blood culture B) Abscess formation C) Clinical improvement D) All of the above

Question 6: When might a patient with spondylodiscitis be transitioned from intravenous to oral antibiotics?

A) Immediately upon diagnosis B) After surgical intervention C) Once blood cultures are taken D) When they show clinical improvement and are stable

Question 7: Why is close monitoring of patients with spondylodiscitis essential during treatment?

A) To assess treatment efficacy B) To prevent antibiotic resistance C) To reduce healthcare costs D) To guide surgical interventions

Question 8: What should patients do to prevent relapse and the development of antibiotic resistance during spondylodiscitis treatment?

A) Start antibiotic treatment as soon as possible B) Take antibiotics until they feel better C) Complete the full course of antibiotics as prescribed D) Reduce the antibiotic dose gradually

Question 9: In what situation might a combination of a broad-spectrum-β-lactam antibiotic with an additional glycopeptide antibiotic be justified in spondylodiscitis treatment?

A) In all cases B) When blood cultures are negative C) In patients with severe sepsis once blood cultures have been taken D) In patients with mild infection

Question 10: What is the potential drawback of starting empirical broad-spectrum antibiotic therapy in spondylodiscitis?

A) Reduced treatment efficacy B) Increased rates of Clostridium difficile-associated diarrhea C) Lower healthcare costs D) Shorter hospital stays

Answers:

D) Positive blood culture D) To provide immediate treatment while awaiting culture results B) Escherichia coli D) 6-12 weeks or longer D) All of the above D) When they show clinical improvement and are stable A) To assess treatment efficacy C) Complete the full course of antibiotics as prescribed C) In patients with severe sepsis once blood cultures have been taken B) Increased rates of Clostridium difficile-associated diarrhea