Vertebral osteomyelitis in patients with an underlying malignancy or chronic kidney disease - who is at higher risk for adverse outcome?

Abstract

Purpose: Patients with vertebral osteomyelitis (VO) and comorbidities, notably chronic kidney disease (CKD), are at risk of early mortality. The aim of this study was to compare characteristics and outcomes of VO patients with an underlying malignancy (ONCO) to VO patients with CKD and VO patients without comorbidities (CONTROL).

Methods: We performed a retrospective analysis of data which was prospectively collected between 2008 and 2020. Primary outcome was treatment failure defined as death and/or recurrence of VO within one year.

Results: 241 VO patients (ONCO = 56; CKD = 47; CONTROL = 138) were analysed. Treatment failure occurred in 26% of ONCO and 45% of CKD patients. Staphylococcus aureus was the most common causative pathogen in the CKD (57%) and CONTROL group (43%). ONCO patients showed a broader distribution of common VO-causing pathogens, with coagulase-negative staphylococci (CoNS) accounting for the highest proportion of causative bacteria (27%). Nevertheless, S.aureus was associated with a significantly higher risk of treatment failure in VO ONCO patients.

Conclusion: Treatment failure in VO CKD patients was twice as high as in VO ONCO patients. However, both groups showed high treatment failure rates. CoNS should be considered when starting empirical antibiotic treatment in VO ONCO patients. Moreover, oncological patients with VO caused by S.aureus should be monitored closely.

Keywords: 1-year-mortality; Chronic kidney disease; CoNS; Coagulase-negative staphylococci; Malignancy; Malignant disease; Recurrence; S.aureus; Spondylodiscitis; Staphylococcus aureus; Treatment failure; Vertebral osteomyelitis.

Fig. 1

Characteristic MRI of VO in L3/4 and L5/S1. MRI of the lumbar spine of a patient presenting to the emergency department with fever, severe back pain, and elevated inflammatory markers (C-reactive protein 74 mg/L, leukocytes 12.000/µL). On STIR sequences, there was signal enhancement in the intervertebral disc and the superior and inferior endplates of the L5/S1 motion segment, accompanied by corresponding contrast enhancement (highlighted with arrows). Additionally, there was mild contrast uptake in the adjacent paravertebral soft tissues. In light of the clinical presentation, VO was strongly suspected in the L5/S1 segment. Minor changes were also observed in the L3/L4 segment (highlighted in red colour), where early inflammatory changes were also possible. Enterococcus faecalis was detected in blood cultures and in the intraoperative samples of the L3/4 and L5/S1 discs and verified the diagnosis of VO

Fig. 2

Kaplan–Meier curve. The Kaplan–Meier curve displays 1-year survival of CONTROL, ONCO and CKD patients within the first year after diagnosis of VO