PYOGENIC SPONDYLODISCITIS: RISK FACTORS FOR THERAPEUTIC FAILURE AND RECURRENCE

Danda, Guilherme José da Nóbrega; Castro, Cleudson Nery de

doi:10.1590/S1808-185120232202268880

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Original article, Tumor/Infection • Coluna/Columna. 22 (2) • 2023 • https://doi.org/10.1590/S1808-185120232202268880 copy

PYOGENIC SPONDYLODISCITIS: RISK FACTORS FOR THERAPEUTIC FAILURE AND RECURRENCE

ESPONDILODISCITE PIOGÊNICA: FATORES DE RISCO PARA FALHA TERAPÊUTICA E RECORRÊNCIA

ESPONDILODISCITIS PIÓGENA: FACTORES DE RIESGO PARA FRACASO TERAPÉUTICO Y RECURRENCIA

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Evaluate the prognostic factors associated with therapeutic failure and recurrence in pyogenic spondylodiscitis (PS).

Methods:

A historical cohort study was conducted in a reference Brazilian hospital for locomotor system and neurodevelopmental diseases. All patients with PS treated between January 1999 and December 2018 and followed for at least one year were included. PS was defined based on clinical, laboratory, and radiological criteria. Microbiological data and clinical outcomes at the end of follow-up were also collected and analyzed.

Results:

Fifty patients (mean age 50.94 ± 15.84 years, men 76.00%) were included. After twelve months of follow-up, therapeutic failure was observed in 24.00% (n = 12) and recurrence in 18.00% (n = 09) patients. Among those who were cured, residual symptoms were found in 50.00% (19/38). No deaths were observed. After multivariate analysis, therapeutic failure was associated with the prescription of antibiotic therapy before culture results (p = 0.0153), spinal cord compression (p = 0.0053), and sensory deficits (p = 0.0341). Furthermore, recurrence was associated with previous nonspinal surgeries (p = 0.0350) and spinal cord compression (p = 0.0447).

Conclusion:

PS causes significant morbidity. The prognosis depends mainly on the clinical presentation at admission, especially when associated with spinal cord compression, which reinforces the importance of early diagnosis. Level of Evidence II; Prognostic Studies.

Keywords:
Discitis; Prognosis; Treatment Outcome

Characteristics	Values ^* * Values expressed as mean ± standard deviation or frequency (%). 1. Only two patients were under 18. 2. Malignancy, intravenous drug abuse, end-stage renal disease, congestive heart failure, hepatitis C virus, and previous tuberculosis were reported only once each. 3. There was no record of spondylodiscitis by a contiguous focus of infection.
Age (years)¹1 Akiyama T, Chikuda H, Yasunaga H, Horiguchi H, Fushimi K, Saita K. Incidence and risk factors for mortality of vertebral osteomyelitis: a retrospective analysis using the Japanese diagnosis procedure combination database. BMJ Open. 2013;3(3):e002412.	50.94 ± 15.84
Sex
Male	38 (76.00)
Female	12 (24.00)
Diagnostic delay (months)	6.32 ± 5.27
Clinical manifestations
Back pain	48 (96.00)
Fever	16 (32.00)
Weight loss	20 (40.00)
Radicular pain	18 (36.00)
Neurological deficit (motor or sensory)	11 (22.00)
Spinal deformities	7 (14.00)
Risk factors ²2 Issa K, Diebo BG, Faloon M, Naziri Q, Pourtaheri S, Paulino CB, et al. The Epidemiology of vertebral osteomyelitis in the United States from 1998 to 2013. Clin Spine Surg. 2018;31(2):E102-8.
Diabetes mellitus	6 (12.00)
Hypertension	21 (42.00)
Smoking	7 (14.00)
Alcoholism	8 (16.00)
Disc herniation	13 (26.00)
Spinal osteoarthritis	21 (42.00)
Rheumatological disease	2 (4.00)
Use of immunosuppressive agents	6 (12.00)
Distant bacterial infections (last year)	24 (48.00)
Hospitalization in the last three years	34 (68.00)
Invasive spinal procedures (last three years)	24 (48.00)
Surgery in the last three years (nonspinal)	8 (16.00)
Pathophysiological classification ³3 Lora-Tamayo J, Euba G, Narváez JA, Murillo O, Verdaguer R, Sobrino B, et al. Changing trends in the epidemiology of pyogenic vertebral osteomyelitis : the impact of cases with no microbiologic diagnosis. Semin Arthritis Rheum. 2011;41(2):247-55.
Hematogenous spondylodiscitis	29 (58.00)
Spondylodiscitis by direct inoculation	21 (42.00)

Characteristics	Values ^* * Values expressed as frequency (%).
Affected level
Cervical	2 (4.00)
Thoracic	9 (18.00)
Thoracolumbar	4 (8.00)
Lumbar	21 (42.00)
Lumbosacral	14 (28.00)
Number of vertebrae affected
Two vertebrae	40 (80.00)
More than two vertebrae	10 (20.00)
Complications
Psoas abscess	1 (2.00)
Paravertebral abscess	8 (16.00)
Epidural abscess	5 (10.00)
Paravertebral phlegmon	9 (18.00)
Epidural phlegmon	4 (8.00)
Spinal cord compression	8 (16.00)
Cauda equina compression	2 (4.00)

Characteristics	Values *
Treatment modalities
Nonsurgical	33 (66.00)
Surgical	17 (34.00)
Use of orthoses	38 (76.00)
Type of antibiotic therapy
Exclusively empiric therapy	11 (22.00)
Exclusively definitive therapy based on microbiology results	28 (56.00)
Empiric followed by definitive therapy based on microbiology results	11 (22.00)
Antimicrobial treatment time (weeks)
Intravenous	5.07 ± 2.49
Oral	4.44 ± 2.89
Total	9.33 ± 3.08
Hospital length of stay (days)	55.88 ± 31.22
Outcomes - during one-year follow-up
Deaths	0 (0.00)
Recurrence	9 (18.00)
Outcomes – in the first medical evaluation after a one-year follow-up
Cured without sequelae	19 (38.00)
Cured with sequelae (neurological impairment or chronic pain)	19 (38.00)
Therapeutic failure	12 (24.00)

	Risk Relative (RR)		RR Adjusted
Variables	RR (95 % CI)	p-value	RR (95% IC)	p-value
Diagnostic delay > 6 months	1.93 (0.71 – 5.26)	0.1967	2.23 (0.50 – 9.89)	0.2923
Alcoholism	2.62 (1.03 – 6.67)	0.0424	1.99 (0.54 – 7.34)	0.3037
Surgery in the last three years (nonspinal)	2.62 (1.03 – 6.67)	0.0424	1.30 (0.22 – 7.73)	0.7755
Spondylodiscitis (pathophysiological classification)		0.0605		0.2328
Direct inoculation	2.76 (0.96 – 7.98)	0.0605	2.29 (0.59 – 8.91)	0.2328
Hematogenous	1	-	1	-
Spinal cord compression (imaging evaluation)	3.75 (1.58 – 8.89)	0.0027	5.27 (1.64 – 16.95)	0.0053
More than two vertebrae affected	2.86 (1.14 – 7.13)	0.0245	2.14 (0.46 – 9.98)	0.3303
Type of antibiotic therapy		0.1343		0.0260
Exclusively empiric therapy	0.42 (0.06 – 3.13)	0.4005	1.05 (0.11 – 9.80)	0.9688
Exclusively definitive therapy based on microbiology results	1	-	1	-
Empiric followed by definitive therapy based on microbiology results	2.12 (0.81 – 5.54)	0.1248	3.82 (1.29 – 11.27)	0.0153
Sensory deficit at admission	2.27 (0.86 – 5.88)	0.0925	4.76 (1.12 – 20.17)	0.0341
Total antimicrobial treatment time > eight weeks	2.35 (0.81 – 6.80)	0.1158	1.90 (0.43 – 8.37)	0.3963
Pyogenic spondylodiscitis caused by multidrug-resistant bacteria¹ 1 Methicillin-resistant Staphylococcus aureus (n= 06), multidrug-resistant Pseudomonas aeruginosa (n= 02), and extended-spectrum β-lactamase producing Gram-negative bacteria (n= 02).	4.00 (1.63 – 9.78)	0.0024	0.97 (0.23 – 4.04)	0.9666

	Hazard Ratio (HR)		HR Adjusted
Variables	HR (95 % IC)	p-value	HR (95 % IC)	p-value
Age ≥ 60 years old	5.44 (0.67 – 43.86)	0.1119	3.55 (0.27 – 46.62)	0.3347
Hypertension	3.40 (0.75 – 15.38)	0.1120	2.28 (0.39 – 13.44)	0.3607
Nonspinal surgeries in the last three years	9.35 (1.71 – 51.11)	0.0099	5.74 (1.00 – 34.37)	0.0350
Erythrocyte sedimentation rate > 15 mm in the first hour at admission	4.45 (0.47 – 42.28)	0.1934	3.93 (0.21 – 72.27)	0.3573
Spinal cord compression (imaging evaluation)	5.94 (1.56 – 22.57)	0.0089	3.83 (1.00 – 15.97)	0.0447
Pyogenic spondylodiscitis caused by multidrug-resistant bacteria¹ 1 Methicillin-resistant Staphylococcus aureus (n= 06), multidrug-resistant Pseudomonas aeruginosa (n= 02), and extended-spectrum β-lactamase-producing Gram-negative bacteria (n= 02).	2.67 (0.66 – 10.82)	0.1693	0.38 (0.03 – 4.32)	0.4346

	Therapeutic failure			Recurrence
Variables*	Yes	No	p-value **	Yes	No	p-value**
Etiological Agent			0.2088			0.2141
Staphylococcus aureus	5 (26.32)	14 (73.68)		6 (31.58)	13 (68.42)
Other Gram-positive	2 (20.00)	8 (80.00)		1 (10.00)	9 (90.00)
Gram-negative	4 (40.00)	6 (60.00)		2 (20.00)	8 (80.00)
Negative culture	0 (0.00)	9 (100.00)		0 (0.00)	9 (100.00)
No culture collected	1 (50.00)	1 (50.00)		0 (0.00)	2 (100.00)
Spine segments			0.305			0.406
Cervical	1 (50.00)	1 (50.00)		1 (50.00)	1 (50.00)
Thoracic	3 (33.33)	6 (66.67)		2 (22.22)	7 (77.78)
Thoracolumbar	2 (50.00)	2 (50.00)		1(25.00)	3 (75.00)
Lumbar	5 (23.81)	16 (76.19)		5 (23.81)	16 (76.19)
Lumbosacral	1 (7.14)	13 (92.86)		0 (0.00)	14 (100.00)
Treatment modalities			0.294			0.465
Nonsurgical	6 (18.18)	27 (81.82)		5 (15.15)	28 (84.85)
Surgical	6 (35.30)	11 (64.70)		4 (23.53)	13 (76.47)

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E-mail: coluna.columna@uol.com.br

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[1] Correspondence: Guilherme José da Nóbrega Danda. Hospital Sarah Brasília, SMHS 501 Bloco A, Brasília, DF, Brazil. 70335901. guilhermedanda@yahoo.com.br