今日の臨床サポート

化膿性脊椎炎

著者: 藤田崇宏 独立行政法人 国立病院機構 北海道がんセンター 感染症内科

監修: 大曲貴夫 国立国際医療研究センター

著者校正/監修レビュー済:2021/11/02
参考ガイドライン:
  1. Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, et al.:2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015 Sep;61(6):e26-46.
患者向け説明資料

概要・推奨   

  1. 化膿性脊椎炎の画像診断にはMRIが最も有用である(推奨度1)。
  1. 治療開始から1カ月目での治療効果判定と予後推測には血沈、CRPが有用である(推奨度2)。
  1. MRIは診断には有用だが、臨床的効果がある場合でも所見の改善に時間がかかるため、治療効果判定には用いるべきではない(推奨度3)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
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  1. Candidaによる骨髄炎に対しては、感受性があればフルコナゾールで治療する。代替薬としてキャンディン系またはアムホテリシンを用いる(推奨度1)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
藤田崇宏 : 特に申告事項無し[2021年]
監修:大曲貴夫 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(大きな変更点はなし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 化膿性脊椎炎の病態は、血行性の細菌の播種、周辺の感染巣からの直接的波及、脊椎手術時の汚染が挙げられる。
  1. 近年は、血管内デバイスの留置の増加により、特に黄色ブドウ球菌による血行性の化膿性脊椎炎が増加している。
  1. 黄色ブドウ球菌の菌血症が判明した場合は、化膿性脊椎炎の合併の可能性を念頭に置くべきである。
  1. グラム陰性桿菌が原因の場合は尿路由来であることが多い。
  1. 血行性と考えられる化膿性脊椎炎を診断した場合は、感染性心内膜炎が合併していないかを検索するべきである。
  1. 合併症として、硬膜外膿瘍、椎体周囲の膿瘍形成、腸腰筋膿瘍が起こる。
  1. 黄色ブドウ球菌による化膿性脊椎炎に合併した腸腰筋膿瘍のCT:図<図表>
  1. 抗菌薬投与が長期間になるため、できるかぎり原因微生物を同定して治療するのが望ましい。経験的な治療は、適切な培養検体が得られてから開始する。
問診・診察のポイント  
  1. 発熱の有無を確認する。

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文献 

著者: Werner Zimmerli
雑誌名: N Engl J Med. 2010 Mar 18;362(11):1022-9. doi: 10.1056/NEJMcp0910753.
Abstract/Text
PMID 20237348  N Engl J Med. 2010 Mar 18;362(11):1022-9. doi: 10.1056/・・・
著者: Gouliouris Theodore T, Aliyu Sani H SH, Brown Nicholas M NM
雑誌名: J Antimicrob Chemother. 2010 Nov;65 Suppl 3:iii11-24. doi: 10.1093/jac/dkq303.
Abstract/Text Spondylodiscitis, a term encompassing vertebral osteomyelitis, spondylitis and discitis, is the main manifestation of haematogenous osteomyelitis in patients aged over 50 years. Staphylococcus aureus is the predominant pathogen, accounting for about half of non-tuberculous cases. Diagnosis is difficult and often delayed or missed due to the rarity of the disease and the high frequency of low back pain in the general population. In this review of the published literature, we found no randomized trials on treatment and studies were too heterogeneous to allow comparison. Improvements in surgical and radiological techniques and the discovery of antimicrobial therapy have transformed the outlook for patients with this condition, but morbidity remains significant. Randomized trials are needed to assess optimal treatment duration, route of administration, and the role of combination therapy and newer agents.

PMID 20876624  J Antimicrob Chemother. 2010 Nov;65 Suppl 3:iii11-24. d・・・
著者: Mylona E E, Samarkos M M, Kakalou E E, Fanourgiakis P P, Skoutelis A A
雑誌名: Semin Arthritis Rheum. 2009 Aug;39(1):10-7. doi: 10.1016/j.semarthrit.2008.03.002. Epub 2008 Jun 11.
Abstract/Text OBJECTIVES: Vertebral osteomyelitis is a cause of back pain that can lead to neurologic deficits if not diagnosed in time and effectively treated. The objective of this study was to systematically review the clinical characteristics of pyogenic vertebral osteomyelitis (PVO).
METHODS: The authors conducted a systematic review of the English literature. The inclusion criteria included studies with 10 or more subjects diagnosed with PVO based on the combination of clinical presentation with either a definitive bacteriologic diagnosis or pathological and/or imaging studies.
RESULTS: The 14 studies that met selection criteria included 1008 patients with PVO. Of them, the majority (62%) were men, with back pain and fever as the most common presenting symptoms. Diabetes mellitus was the most common underlying medical illness, while the urinary tract was the commonest source of infection. Staphylococcus aureus was the most commonly isolated organism. Computed tomographic guided or open biopsy yielded the causative organism more often than blood cultures (77% versus 58%). Plain radiography showed abnormalities in 89% of the cases, while bone scanning and computed tomography or magnetic resonance imaging were positive in 94% of the cases, revealing lumbar as the most commonly affected area. The attributable mortality was 6%, while relapses and neurological deficits were described in the 32% and 32% of the cases, respectively.
CONCLUSION: PVO is an illness of middle-aged individuals with underlying medical illnesses. Although the mortality rate is low, relapses and neurological deficits are common, making early diagnosis a major challenge for the physician.

PMID 18550153  Semin Arthritis Rheum. 2009 Aug;39(1):10-7. doi: 10.101・・・
著者: Modic M T MT, Feiglin D H DH, Piraino D W DW, Boumphrey F F, Weinstein M A MA, Duchesneau P M PM, Rehm S S
雑誌名: Radiology. 1985 Oct;157(1):157-66.
Abstract/Text Thirty-seven patients who were clinically suspected of having vertebral osteomyelitis were prospectively evaluated with magnetic resonance (MR), radiography, and radionuclide studies. These findings were correlated with the final clinical, microbiologic, or histologic diagnoses. Based on the results of these latter studies, 23 patients were believed to have osteomyelitis. MR examinations consisted of at least a sagittal image (TE = 30 msec, TR = 0.5 sec) and an image obtained at TE = 120 msec, TR = 2-3 sec. All patients underwent radiographic and MR examinations, 36 underwent technetium 99m-HDP bone scanning, and 20 patients underwent gallium 67 scanning. Nineteen patients underwent both bone and gallium scanning. The imaging studies were reviewed independently by investigators blinded to the final diagnoses. MR had a sensitivity of 96%, specificity of 92%, and accuracy of 94%. Combined gallium and bone scan studies (19 cases) had a sensitivity of 90%, specificity of 100%, and accuracy of 94%. Bone scans alone had a sensitivity of 90%, specificity of 78%, and accuracy of 86%. Plain radiographs had a sensitivity of 82%, specificity of 57%, and accuracy of 73%. The MR appearance of vertebral osteomyelitis in this study was characteristic, and MR was as accurate and sensitive as radionuclide scanning in the detection of osteomyelitis.

PMID 3875878  Radiology. 1985 Oct;157(1):157-66.
著者: Ledermann Hans Peter HP, Schweitzer Mark E ME, Morrison William B WB, Carrino John A JA
雑誌名: Radiology. 2003 Aug;228(2):506-14. doi: 10.1148/radiol.2282020752. Epub 2003 Jun 11.
Abstract/Text PURPOSE: To systematically evaluate magnetic resonance (MR) imaging findings described as being indicative of spinal infection in patients with proven spinal infection.
MATERIALS AND METHODS: Contrast material-enhanced spinal MR images obtained in 46 consecutive patients (22 women, 24 men; mean age, 58.2 years) with culture or histologic examination results positive for spinal infection were systematically evaluated by two observers. Tuberculous and postoperative infections were excluded. Disk signal intensity and disk height, presence of the nuclear cleft, vertebral signal intensity alterations, endplate erosions on T1-weighted MR images, and presence of paraspinal or epidural inflammation were evaluated. Patient charts and surgical reports were reviewed.
RESULTS: In the 44 patients with disk infection, MR imaging criteria with good to excellent sensitivity included presence of paraspinal or epidural inflammation (n = 43, 97.7% sensitivity), disk enhancement (n = 42, 95.4% sensitivity), hyperintensity or fluid-equivalent disk signal intensity on T2-weighted MR images (n = 41, 93.2% sensitivity), and erosion or destruction of at least one vertebral endplate (n = 37, 84.1% sensitivity). Effacement of the nuclear cleft was only applicable in 18 patients (n = 15, 83.3% sensitivity). Criteria with low sensitivity included decreased height of the intervertebral space (n = 23, 52.3% sensitivity) and disk hypointensity on T1-weighted MR images (n = 13, 29.5% sensitivity). Involvement of several spinal levels occurred in seven (16%) patients. Other spinal infections included isolated vertebral osteomyelitis (n = 1) and primary epidural abscess (n = 1).
CONCLUSION: Most MR imaging criteria commonly used to diagnose disk infections offer good to excellent sensitivity. In atypical manifestations of proven spinal infections, however, some of the classically described MR imaging criteria may not be observed.

Copyright RSNA, 2003.
PMID 12802004  Radiology. 2003 Aug;228(2):506-14. doi: 10.1148/radiol.・・・
著者: Sharif H S HS
雑誌名: AJR Am J Roentgenol. 1992 Jun;158(6):1333-45.
Abstract/Text Infection of the spine is a major category of spinal disease that is difficult to differentiate clinically from degenerative disease, noninfective inflammatory lesions, and spinal neoplasm. The infection can affect the vertebrae, intervertebral disks, paraspinal soft tissues, the epidural space, the meninges, and/or the spinal cord. Specific causative organisms include bacteria (pyogenic, granulomatous), fungi, parasites (Echinococcus, Schistosoma), and viruses. Early diagnosis and prompt treatment are essential to prevent permanent neurologic deficit and/or spinal deformity. Imaging plays an important role in the overall evaluation of these lesions, and the ideal technique is expected to provide information that will help characterize and delineate the disease process, guide biopsy and/or drainage procedures, suggest method of treatment (medical vs surgical), and assess response to therapy. The aim of this article is to review the advantages and limitations of MR imaging in the management of spinal infections.

PMID 1590137  AJR Am J Roentgenol. 1992 Jun;158(6):1333-45.
著者: Elie F Berbari, Souha S Kanj, Todd J Kowalski, Rabih O Darouiche, Andreas F Widmer, Steven K Schmitt, Edward F Hendershot, Paul D Holtom, Paul M Huddleston, Gregory W Petermann, Douglas R Osmon, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2015 Sep 15;61(6):e26-46. doi: 10.1093/cid/civ482. Epub 2015 Jul 29.
Abstract/Text These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention.

© The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
PMID 26229122  Clin Infect Dis. 2015 Sep 15;61(6):e26-46. doi: 10.1093・・・
著者: Liu Catherine C, Bayer Arnold A, Cosgrove Sara E SE, Daum Robert S RS, Fridkin Scott K SK, Gorwitz Rachel J RJ, Kaplan Sheldon L SL, Karchmer Adolf W AW, Levine Donald P DP, Murray Barbara E BE, J Rybak Michael M, Talan David A DA, Chambers Henry F HF, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2011 Feb 1;52(3):e18-55. doi: 10.1093/cid/ciq146. Epub 2011 Jan 4.
Abstract/Text Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.

PMID 21208910  Clin Infect Dis. 2011 Feb 1;52(3):e18-55. doi: 10.1093/・・・
著者: Pigrau Carlos C, Almirante Benito B, Flores Xavier X, Falco Vicenç V, Rodríguez Dolors D, Gasser Isabel I, Villanueva Carlos C, Pahissa Albert A
雑誌名: Am J Med. 2005 Nov;118(11):1287. doi: 10.1016/j.amjmed.2005.02.027.
Abstract/Text PURPOSE: The relationship between pyogenic vertebral osteomyelitis and infectious endocarditis is uncertain. This study investigates the incidence and risk factors of infectious endocarditis in patients with pyogenic vertebral osteomyelitis, and the outcome of pyogenic vertebral osteomyelitis with and without associated infectious endocarditis.
METHODS: A retrospective record review was conducted of all cases of vertebral osteomyelitis from January 1986 to June 2002, occurring in a tertiary referral hospital. Patients were followed for at least 6 months with careful attention to detection of infectious endocarditis and relapses.
RESULTS: Among 606 patients with infectious endocarditis, 28 (4.6%) had pyogenic vertebral osteomyelitis. Among 91 cases of pyogenic vertebral osteomyelitis, 28 (30.8%) had infectious endocarditis. In 6 patients with no clinical signs of infectious endocarditis, the disease was established by routine echocardiography. Infectious endocarditis was more common in patients with predisposing heart conditions and streptococcal pyogenic vertebral osteomyelitis infection. Overall, pyogenic vertebral osteomyelitis in-hospital mortality was 11% (7.1% with infectious endocarditis). Twelve of 25 patients with infectious endocarditis with uncomplicated pyogenic vertebral osteomyelitis were treated for 4 to 6 weeks (endocarditis protocol), with no pyogenic vertebral osteomyelitis relapses.
CONCLUSIONS: When specifically sought, the incidence of infectious endocarditis is high in patients with pyogenic vertebral osteomyelitis. Oral therapy may be an option for uncomplicated pyogenic vertebral osteomyelitis; nevertheless, in gram-positive infections, this approach should only be considered after excluding infectious endocarditis. Favorable outcome with shorter treatment in uncomplicated pyogenic vertebral osteomyelitis associated with infectious endocarditis suggests that prolonged therapy may not be needed in this subgroup except for those infected by difficult to treat microorganisms, such as methicillin-resistant Staphylococcus aureus or Candida spp.

PMID 16271915  Am J Med. 2005 Nov;118(11):1287. doi: 10.1016/j.amjmed.・・・
著者: Le Moal G G, Roblot F F, Paccalin M M, Sosner P P, Burucoa C C, Roblot P P, Becq-Giraudon B B
雑誌名: Eur J Clin Microbiol Infect Dis. 2002 Sep;21(9):671-5. doi: 10.1007/s10096-002-0798-x. Epub 2002 Sep 10.
Abstract/Text Spondylodiscitis is rarely observed in association with infective endocarditis (IE). In the study presented here, 92 cases of definite IE were examined. Spondylodiscitis was present in 14 (15%) cases. The mean age of patients with spondylodiscitis was 69.1+/-13.6 years (range, 33-87 years). The male-to-female ratio was 8:6. Predisposing heart disease was found in nine (64.3%) cases. Back pain was reported in all cases. Spondylodiscitis was diagnosed before endocarditis in all cases. The infection affected the lumbar spine in 10 (71%) cases. A bacterium was isolated in all cases: group D Streptococcus ( n=5; 35.7%), coagulase-negative Staphylococcus ( n=4; 28.6%), and others ( n=5). Endocarditis affected predominantly the aortic valve (43%). The outcome was favourable in 12 cases. No differences in clinical features, evolution of disease, or laboratory values were found between IE patients with and IE patients without spondylodiscitis. Spondylodiscitis does not appear to worsen prognosis of IE, although the need for cardiac valve replacement seems to be more frequent in IE patients with spondylodiscitis. IE should be included in the differential diagnosis in patients with infectious spondylodiscitis and risk factors for endocarditis. In such patients, echocardiography should be performed routinely.

PMID 12373500  Eur J Clin Microbiol Infect Dis. 2002 Sep;21(9):671-5. ・・・
著者: Stryjewski Martin E ME, Szczech Lynda A LA, Benjamin Daniel K DK Jr, Inrig Jula K JK, Kanafani Zeina A ZA, Engemann John J JJ, Chu Vivian H VH, Joyce Maria J MJ, Reller L Barth LB, Corey G Ralph GR, Fowler Vance G VG Jr
雑誌名: Clin Infect Dis. 2007 Jan 15;44(2):190-6. doi: 10.1086/510386. Epub 2006 Dec 8.
Abstract/Text BACKGROUND: Because of its ease of dosing, vancomycin is commonly used to treat methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia in patients undergoing long-term hemodialysis. Clinical outcomes resulting from such a therapeutic strategy have not been well defined.
METHODS: We prospectively identified patients undergoing long-term hemodialysis who received a diagnosis of MSSA bacteremia. Clinical outcomes were grouped according to the predominant antibiotic received during their therapy (vancomycin or a first-generation cephalosporin [cefazolin]). Treatment failure (defined as death or recurrent infection) was determined at 12 weeks after the initial positive blood culture results. A multivariable analysis was used to adjust for confounders.
RESULTS: During an 84-month period, 123 hemodialysis-dependent patients with MSSA bacteremia were identified. Patients receiving vancomycin (n=77) tended to be younger (51 vs. 57 years; P=.06) and had a lower rates of metastatic complications at presentation (11.7% vs. 36.7%; P=.001) than did those receiving cefazolin (n=46). The 2 groups were similar with regard to Acute Physiology and Chronic Health Evaluation II scores, comorbidities, source of infection, type of hemodialysis access, and access removal rates. Treatment failure was more common among patients receiving vancomycin (31.2% vs. 13%; P=.02). In the multivariable analysis, factors independently associated with treatment failure included vancomycin use (odds ratio, 3.53; 95% confidence interval, 1.15-13.45) and retention of the hemodialysis access (odds ratio, 4.99; 95% confidence interval, 1.89-13.76).
CONCLUSIONS: Hemodialysis-dependent patients with MSSA bacteremia treated with vancomycin are at a higher risk of experiencing treatment failure than are those receiving cefazolin. In the absence of patient specific circumstances (e.g., allergy to beta-lactams), vancomycin should not be continued beyond empirical therapy for hemodialysis-dependent patients with MSSA bacteremia.

PMID 17173215  Clin Infect Dis. 2007 Jan 15;44(2):190-6. doi: 10.1086/・・・
著者: Pappas Peter G PG, Kauffman Carol A CA, Andes David D, Benjamin Daniel K DK Jr, Calandra Thierry F TF, Edwards John E JE Jr, Filler Scott G SG, Fisher John F JF, Kullberg Bart-Jan BJ, Ostrosky-Zeichner Luis L, Reboli Annette C AC, Rex John H JH, Walsh Thomas J TJ, Sobel Jack D JD, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2009 Mar 1;48(5):503-35. doi: 10.1086/596757.
Abstract/Text Guidelines for the management of patients with invasive candidiasis and mucosal candidiasis were prepared by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replace the previous guidelines published in the 15 January 2004 issue of Clinical Infectious Diseases and are intended for use by health care providers who care for patients who either have or are at risk of these infections. Since 2004, several new antifungal agents have become available, and several new studies have been published relating to the treatment of candidemia, other forms of invasive candidiasis, and mucosal disease, including oropharyngeal and esophageal candidiasis. There are also recent prospective data on the prevention of invasive candidiasis in high-risk neonates and adults and on the empiric treatment of suspected invasive candidiasis in adults. This new information is incorporated into this revised document.

PMID 19191635  Clin Infect Dis. 2009 Mar 1;48(5):503-35. doi: 10.1086/・・・
著者: Carragee E J EJ, Kim D D, van der Vlugt T T, Vittum D D
雑誌名: Spine (Phila Pa 1976). 1997 Sep 15;22(18):2089-93.
Abstract/Text STUDY DESIGN: Retrospective chart review of 44 cases.
OBJECTIVE: To describe the clinical usage of the erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis.
SUMMARY OF BACKGROUND DATA: The erythrocyte sedimentation rate is often used to determine the efficacy and duration of treatment in pyogenic vertebral osteomyelitis. Although consensus and anecdotal reports support this notion, no detailed review of the erythrocyte sedimentation rate response in conservative treatment of pyogenic vertebral osteomyelitis has been made, to date.
METHODS: For 44 patients with pyogenic vertebral osteomyelitis who had erythrocyte sedimentation rate testing at or before the time of diagnosis and at least twice during the next month, the clinical findings and results of the erythrocyte sedimentation rate testing were reviewed.
RESULTS: Of 18 cases with no significant fall in the erythrocyte sedimentation rate during the first month, 9 (50%) failed conservative treatment. Conversely, of the 26 cases with a good erythrocyte sedimentation rate response during the first month, three (12%) were clinical failures. However, a rapid decline of the erythrocyte sedimentation rate (> 50% in the first month) is rarely seen in treatment failure. In addition, approximately 2 weeks after antibiotic treatment, 19 of 32 were actually higher than at the time of diagnosis, but went on to clinical cure without surgery. The erythrocyte sedimentation rate, in combination with the patient's age and immune status, predicted the success of antibiotic treatment, in most cases. The erythrocyte sedimentation rate response alone during the first month was not a clear predictor of success.
CONCLUSIONS: Although the erythrocyte sedimentation rate does correlate well with response to treatment as a general rule, care must be taken in interpretation of a persistently elevated or even rising erythrocyte sedimentation rate as an isolated clinical finding.

PMID 9322319  Spine (Phila Pa 1976). 1997 Sep 15;22(18):2089-93.
著者: Kowalski T J TJ, Layton K F KF, Berbari E F EF, Steckelberg J M JM, Huddleston P M PM, Wald J T JT, Osmon D R DR
雑誌名: AJNR Am J Neuroradiol. 2007 Apr;28(4):693-9.
Abstract/Text BACKGROUND AND PURPOSE: Follow-up MR imaging examinations are increasingly used to monitor response to treatment in patients with spine infection. We aim to describe follow-up MR imaging examination findings 4-8 weeks after diagnosis and initiation of treatment of spine infections and to compare with clinical findings.
MATERIALS AND METHODS: Thirty-three patients with spinal infection and available baseline and 4-8-week follow-up MRIs were included in this retrospective cohort study. Baseline and follow-up MR imaging were graded by 2 neuroradiologists blinded to clinical characteristics and outcome. Clinical findings and outcomes were independently obtained by retrospective review of the medical record.
RESULTS: Compared with baseline MR imaging examinations, follow-up MR imaging more frequently demonstrated vertebral body loss of height (26/33 [79%] versus 14/33 [47%]; P < .001) and less frequently demonstrated epidural enhancement (19/32 [59%] versus 29/33 [88%]; P = .008), epidural canal abscess (3/32 [9%] versus 15/33 [45%]; P = .001), and epidural canal compromise (10/32 [31%] versus 19/33 [58%]; P = .008). Most follow-up MR imaging examinations demonstrated less paraspinal inflammation and less epidural enhancement compared with baseline. However, vertebral body enhancement, disk space enhancement, and bone marrow edema more often were equivocal or appeared worse compared with baseline. Twenty-one of 32 (66%) follow-up MR imaging examination overall grades were considered improved, 5 (16%) were equivocal, and 6 (19%) were worse. No single MR imaging finding was associated with clinical status.
CONCLUSION: Soft tissue findings, not bony findings, should be the focus of clinicians interpreting follow-up MR imaging results. No single MR imaging parameter was associated with the patients' clinical status.

PMID 17416823  AJNR Am J Neuroradiol. 2007 Apr;28(4):693-9.
著者: Zarrouk V V, Feydy A A, Sallès F F, Dufour V V, Guigui P P, Redondo A A, Fantin B B
雑誌名: Rheumatology (Oxford). 2007 Feb;46(2):292-5. doi: 10.1093/rheumatology/kel228. Epub 2006 Jul 28.
Abstract/Text OBJECTIVES: Magnetic resonance imaging (MRI) and computed tomography (CT) are useful for initial assessment of bacterial spondylodiscitis. However, clinical relevance of imaging changes during treatment is less well-documented.
METHODS: Between October 1997 and March 2005, 29 patients with documented bacterial spondylodiscitis were prospectively enrolled. They had clinical, biological and imaging examinations (MRI and/or CT) at M0 and M3, and in 22 cases, at M6.
RESULTS: Mean age was 58 yrs. Antimicrobial chemotherapy lasted an average of 98 days. The median follow-up was 18 months, including 12 months after the completion of treatment. Infection was cured in every patient. Biological markers of inflammation returned to normal at M3. Six patients had painful and/or neurological sequelae. Decreased disc height was a consistent and early sign, and remained stable during the follow-up. Vertebral oedema, present in 100% of cases initially, persisted in 67 and 15% of cases at M3 and M6, respectively. Discal abscesses and paravertebral abscesses, present in 65 and 39% of cases initially, persisted in, respectively, 42 and 9% of cases at M3 and in 18 and 3% of cases at M6. Epidural abscesses were present at diagnosis in 30% of cases, and had always disappeared by M3. Imaging abnormalities found at M0 and M3 did not differ between patients with and without late neurological or painful sequelae.
CONCLUSIONS: Imaging abnormalities often persist in patients with bacterial spondylodiscitis despite a favourable clinical and biological response to antibiotic treatment. They are not associated with relapses, neurological sequelae or persistent pain. Imaging controls are not necessary when bacterial spondylodiscitis responds favourably to treatment.

PMID 16877464  Rheumatology (Oxford). 2007 Feb;46(2):292-5. doi: 10.10・・・
著者: Kowalski Todd J TJ, Berbari Elie F EF, Huddleston Paul M PM, Steckelberg James M JM, Osmon Douglas R DR
雑誌名: Clin Infect Dis. 2006 Jul 15;43(2):172-9. doi: 10.1086/505118. Epub 2006 Jun 5.
Abstract/Text BACKGROUND: The ability of follow-up imaging examinations to predict treatment failure in patients with spine infections has not been well studied.
METHODS: We conducted a retrospective cohort analysis of patients with spine infection who had both baseline and 4-8-week follow-up imaging results available at the Mayo Clinic (Rochester, MN) during the period of 1994-2002. Follow-up imaging findings were categorized as improved, equivocal, or worse, compared with the baseline findings, on the basis of a simple grading system that focused on associated soft-tissue findings.
RESULTS: Baseline and 4-8-week follow-up imaging findings were available for 79 patients with spine infection who presented to the Mayo Clinic during 1994-2002. Thirty-five infections (44%) were due to Staphylococcus aureus, 9 (11%) were due to coagulase-negative staphylococci, and 16 (20%) were culture negative. Twenty-seven (34%), 38 (48%), and 14 (18%) follow-up images were graded improved, equivocal, or worse, respectively. The cumulative rates of 1-year survival free of microbiologically confirmed treatment failure were 100%, 89% (95% CI, 74%-96%), and 56% (95% CI, 24%-83%) for patients with improved, equivocal, and worse follow-up imaging findings, respectively (P=.004). Only 3 (6%) of 52 patients deemed to have had clinical improvement at the time of the follow-up imaging study experienced treatment failure. Elevated levels of inflammatory biomarkers identified 2 of these patients as high risk for treatment failure, and the levels were not performed for the third patient.
CONCLUSIONS: Applying a simple grading scale to assess follow-up imaging examinations for patients with spinal infection stratifies their risk of treatment failure. Patients' clinical statuses and inflammatory biomarker responses may be helpful for selecting patients at high risk for treatment failure who should undergo follow-up magnetic resonance imaging.

PMID 16779743  Clin Infect Dis. 2006 Jul 15;43(2):172-9. doi: 10.1086/・・・
著者: Malloy Katherine M KM, Davis George A GA
雑誌名: Orthopedics. 2009 Jul;32(7):499. doi: 10.3928/01477447-20090527-18.
Abstract/Text Vancomycin has been used extensively for the treatment of Gram-positive bacterial infections, especially in cases of methicillin-resistant Staphylococcus aureus (MRSA). Despite long-term use, many uncertainties have remained regarding appropriate dosing, monitoring, and toxicity risks. In January 2009, a committee representing the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), and the Society of Infectious Diseases Pharmacists (SIDP) released recommendations for vancomycin monitoring. As osteomyelitis patients are frequent recipients of vancomycin, this article provides a summary of the recommendations in reference to loading and maintenance doses, trough concentration monitoring, frequency of monitoring, and risk of toxicities.

PMID 19634847  Orthopedics. 2009 Jul;32(7):499. doi: 10.3928/01477447-・・・
著者: Chung-Yen Huang, Ronan W Hsieh, Hung-Teng Yen, Tzu-Chun Hsu, Chun-Yu Chen, Yee-Chun Chen, Chien-Chang Lee
雑誌名: Int J Antimicrob Agents. 2019 Mar;53(3):246-260. doi: 10.1016/j.ijantimicag.2019.01.007. Epub 2019 Jan 10.
Abstract/Text Current practice of long-term antibiotic use in patients with osteomyelitis is controversial. Recent studies showed short-term antibiotic use to be non-inferior to long-term use, but the results of these studies have been inconsistent. In this review, the PubMed and Embase databases were searched from inception through to June 2018 for randomised controlled trials (RCTs), cohort studies or case-control studies comparing two different durations of antibiotic use. Short antibiotic courses were defined as antibiotics administered for a shorter period than the recommended 4-6 weeks. A random-effects model was used to calculate summary odds ratios (ORs) of treatment failure in patients treated with short-course antibiotics compared with long-course antibiotics. A total of 15 articles (5 RCTs and 10 observational studies) and 3598 patients were included. The overall OR of treatment failure in patients receiving short-course antibiotics was 1.50 [95% confidence interval (CI) 0.97-2.34]. Subgroup analysis revealed that a short course of antibiotic treatment was associated with an increased treatment failure rate in vertebral osteomyelitis (OR = 2.06, 95% CI 1.18-3.57) while having a similar rate to a long antibiotic course in acute osteomyelitis of childhood (OR = 1.86, 95% CI 0.75-4.64). Meta-regression found a higher proportion of Staphylococcus aureus infection was related to a higher risk of treatment failure in patients with vertebral osteomyelitis (Coef. = 4.996; P = 0.032). Short-course antibiotics are safe and effective in children with acute osteomyelitis. Long-course antibiotics may still be preferred in vertebral osteomyelitis, especially in patients with S. aureus infection.

Copyright © 2019 Elsevier Ltd. All rights reserved.
PMID 30639627  Int J Antimicrob Agents. 2019 Mar;53(3):246-260. doi: 1・・・
著者: Louis Bernard, Aurélien Dinh, Idir Ghout, David Simo, Valerie Zeller, Bertrand Issartel, Vincent Le Moing, Nadia Belmatoug, Philippe Lesprit, Jean-Pierre Bru, Audrey Therby, Damien Bouhour, Eric Dénes, Alexa Debard, Catherine Chirouze, Karine Fèvre, Michel Dupon, Philippe Aegerter, Denis Mulleman, Duration of Treatment for Spondylodiscitis (DTS) study group
雑誌名: Lancet. 2015 Mar 7;385(9971):875-82. doi: 10.1016/S0140-6736(14)61233-2. Epub 2014 Nov 5.
Abstract/Text BACKGROUND: Duration of treatment for patients with vertebral osteomyelitis is mainly based on expert recommendation rather than evidence. We aimed to establish whether 6 weeks of antibiotic treatment is non-inferior to 12 weeks in patients with pyogenic vertebral osteomyelitis.
METHODS: In this open-label, non-inferiority, randomised controlled trial, we enrolled patients aged 18 years or older with microbiologically confirmed pyogenic vertebral osteomyelitis and typical radiological features from 71 medical care centres across France. Patients were randomly assigned to either 6 weeks or 12 weeks of antibiotic treatment (physician's choice in accordance with French guidelines) by a computer-generated randomisation list of permuted blocks, stratified by centre. The primary endpoint was the proportion of patients who were classified as cured at 1 year by a masked independent validation committee, analysed by intention to treat. Non-inferiority would be declared if the proportion of cured patients assigned to 6 weeks of treatment was not less than the proportion of cured patients assigned to 12 weeks of treatment, within statistical variability, by an absolute margin of 10%. This trial is registered with EudraCT, number 2006-000951-18, and Clinical Trials.gov, number NCT00764114.
FINDINGS: Between Nov 15, 2006, and March 15, 2011, 359 patients were randomly assigned, of whom six in the 6-week group and two in the 12-week group were excluded after randomisation. 176 patients assigned to the 6-week treatment regimen and 175 to the 12-week treatment regimen were analysed by intention to treat. 160 (90·9%) of 176 patients in the 6-week group and 159 (90·9%) of 175 of those in the 12-week group met the criteria for clinical cure. The difference between the groups (0·05%, 95% CI -6·2 to 6·3) showed the non-inferiority of the 6-week regimen when compared with the 12-week regimen. 50 patients in the 6-week group and 51 in the 12-week group had adverse events, the most common being death (14 [8%] in the 6-week group vs 12 [7%] in the 12-week group), antibiotic intolerance (12 [7%] vs 9 [5%]), cardiorespiratory failure (7 [4%] vs 12 [7%]), and neurological complications (7 [4%] vs 3 [2%]).
INTERPRETATION: 6 weeks of antibiotic treatment is not inferior to 12 weeks of antibiotic treatment with respect to the proportion of patients with pyogenic vertebral osteomyelitis cured at 1 year, which suggests that the standard antibiotic treatment duration for patients with this disease could be reduced to 6 weeks.
FUNDING: French Ministry of Health.

Copyright © 2015 Elsevier Ltd. All rights reserved.
PMID 25468170  Lancet. 2015 Mar 7;385(9971):875-82. doi: 10.1016/S0140・・・
著者: Ki-Ho Park, Oh-Hyun Cho, Jung Hee Lee, Ji Seon Park, Kyung Nam Ryu, Seong Yeon Park, Yu-Mi Lee, Yong Pil Chong, Sung-Han Kim, Sang-Oh Lee, Sang-Ho Choi, In-Gyu Bae, Yang Soo Kim, Jun Hee Woo, Mi Suk Lee
雑誌名: Clin Infect Dis. 2016 May 15;62(10):1262-1269. doi: 10.1093/cid/ciw098. Epub 2016 Feb 24.
Abstract/Text BACKGROUND: The optimal duration of antibiotic treatment for hematogenous vertebral osteomyelitis (HVO) should be based on the patient's risk of recurrence, but it is not well established.
METHODS: A retrospective review was conducted to evaluate the optimal duration of antibiotic treatment in patients with HVO at low and high risk of recurrence. Patients with at least 1 independent baseline risk factor for recurrence, determined by multivariable analysis, were considered as high risk and those with no risk factor as low risk.
RESULTS: A total of 314 patients with microbiologically diagnosed HVO were evaluable for recurrence. In multivariable analysis, methicillin-resistant Staphylococcus aureus infection (adjusted odds ratio [aOR], 2.61; 95% confidence interval [CI], 1.16-5.87), undrained paravertebral/psoas abscesses (aOR, 4.09; 95% CI, 1.82-9.19), and end-stage renal disease (aOR, 6.58; 95% CI, 1.63-26.54) were independent baseline risk factors for recurrence. Therefore, 191 (60.8%) patients were classified as low risk and 123 (39.2%) as high risk. Among high-risk patients, there was a significant decreasing trend for recurrence according to total duration of antibiotic therapy: 34.8% (4-6 weeks [28-41 days]), 29.6% (6-8 weeks [42-55 days]), and 9.6% (≥8 weeks [≥56 days]) (P = .002). For low-risk patients, this association was still significant but the recurrence rates were much lower: 12.0% (4-6 weeks), 6.3% (6-8 weeks), and 2.2% (≥8 weeks) (P = .02).
CONCLUSIONS: Antibiotic therapy of prolonged duration (≥8 weeks) should be given to patients with HVO at high risk of recurrence. For low-risk patients, a shorter duration (6-8 weeks) of pathogen-directed antibiotic therapy may be sufficient.

© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.
PMID 26917813  Clin Infect Dis. 2016 May 15;62(10):1262-1269. doi: 10.・・・
著者: Legrand E E, Flipo R M RM, Guggenbuhl P P, Masson C C, Maillefert J F JF, Soubrier M M, Noël E E, Saraux A A, Di Fazano C S CS, Sibilia J J, Goupille P P, Chevalie X X, Cantagrel A A, Conrozier T T, Ravaud P P, Lioté F F, Rheumatology Network Organization
雑誌名: Joint Bone Spine. 2001 Dec;68(6):504-9.
Abstract/Text The optimal management of pyogenic discitis is not agreed on. No randomized clinical trials of short-course or oral antibiotic regimens have been published to date. To shed light on this issue, we reviewed the management of patients admitted for pyogenic discitis to one of 12 networked rheumatology departments. In this cross-sectional observational study, each department included the first ten patients admitted starting in January 1997 for treatment of pyogenic discitis. One hundred ten patients met the inclusion criteria, 67 men and 43 women, with a mean age of 60.6 +/- 13.7 years (range, 17-86 years). Mean time from symptom onset to diagnosis was 39.6 +/- 39.8 days (range, 24 h-240 days). Blood cultures were positive in 47.3% of patients, and the percutaneous discal and vertebral biopsy in 63.6% of cases; these two investigations identified the causative organism in 79 cases (72.8%). Mean duration of the rheumatology department stay was 31.3 +/- 14.1 days (range, 4-78 days). Antibiotics were given intravenously to 103 (93.6%) patients, for a mean of 25.5 +/- 17.6 days (range, 4-124 days); duration of intravenous antibiotic therapy was longer than 4 weeks in 36.5% of patients. Only seven (6.4%) patients received primary oral antibiotics with no parenteral antibiotics. One hundred patients were given oral antibiotics at the same time as and after intravenous antibiotics, for a mean duration of 87.2 +/- 43.6 day (range, 20-278 days); Bracing was used in 98 (89.1%) patients. Although antibiotic selection was rational and in agreement with current recommendations, wide differences were noted across centers regarding intravenous treatment duration, hospital stay duration, and total treatment duration.

PMID 11808988  Joint Bone Spine. 2001 Dec;68(6):504-9.
著者: Ho-Kwong Li, Ines Rombach, Rhea Zambellas, A Sarah Walker, Martin A McNally, Bridget L Atkins, Benjamin A Lipsky, Harriet C Hughes, Deepa Bose, Michelle Kümin, Claire Scarborough, Philippa C Matthews, Andrew J Brent, Jose Lomas, Roger Gundle, Mark Rogers, Adrian Taylor, Brian Angus, Ivor Byren, Anthony R Berendt, Simon Warren, Fiona E Fitzgerald, Damien J F Mack, Susan Hopkins, Jonathan Folb, Helen E Reynolds, Elinor Moore, Jocelyn Marshall, Neil Jenkins, Christopher E Moran, Andrew F Woodhouse, Samantha Stafford, R Andrew Seaton, Claire Vallance, Carolyn J Hemsley, Karen Bisnauthsing, Jonathan A T Sandoe, Ila Aggarwal, Simon C Ellis, Deborah J Bunn, Rebecca K Sutherland, Gavin Barlow, Cushla Cooper, Claudia Geue, Nicola McMeekin, Andrew H Briggs, Parham Sendi, Elham Khatamzas, Tri Wangrangsimakul, T H Nicholas Wong, Lucinda K Barrett, Abtin Alvand, C Fraser Old, Jennifer Bostock, John Paul, Graham Cooke, Guy E Thwaites, Philip Bejon, Matthew Scarborough, OVIVA Trial Collaborators
雑誌名: N Engl J Med. 2019 Jan 31;380(5):425-436. doi: 10.1056/NEJMoa1710926.
Abstract/Text BACKGROUND: The management of complex orthopedic infections usually includes a prolonged course of intravenous antibiotic agents. We investigated whether oral antibiotic therapy is noninferior to intravenous antibiotic therapy for this indication.
METHODS: We enrolled adults who were being treated for bone or joint infection at 26 U.K. centers. Within 7 days after surgery (or, if the infection was being managed without surgery, within 7 days after the start of antibiotic treatment), participants were randomly assigned to receive either intravenous or oral antibiotics to complete the first 6 weeks of therapy. Follow-on oral antibiotics were permitted in both groups. The primary end point was definitive treatment failure within 1 year after randomization. In the analysis of the risk of the primary end point, the noninferiority margin was 7.5 percentage points.
RESULTS: Among the 1054 participants (527 in each group), end-point data were available for 1015 (96.3%). Treatment failure occurred in 74 of 506 participants (14.6%) in the intravenous group and 67 of 509 participants (13.2%) in the oral group. Missing end-point data (39 participants, 3.7%) were imputed. The intention-to-treat analysis showed a difference in the risk of definitive treatment failure (oral group vs. intravenous group) of -1.4 percentage points (90% confidence interval [CI], -4.9 to 2.2; 95% CI, -5.6 to 2.9), indicating noninferiority. Complete-case, per-protocol, and sensitivity analyses supported this result. The between-group difference in the incidence of serious adverse events was not significant (146 of 527 participants [27.7%] in the intravenous group and 138 of 527 [26.2%] in the oral group; P=0.58). Catheter complications, analyzed as a secondary end point, were more common in the intravenous group (9.4% vs. 1.0%).
CONCLUSIONS: Oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the first 6 weeks for complex orthopedic infection, as assessed by treatment failure at 1 year. (Funded by the National Institute for Health Research; OVIVA Current Controlled Trials number, ISRCTN91566927 .).

PMID 30699315  N Engl J Med. 2019 Jan 31;380(5):425-436. doi: 10.1056/・・・

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