CLINICAL GUIDELINE FOR

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1 CLINICAL GUIDELINE FOR the investigation and management of inpatients with discitis (vertebral osteomyelitis) 1. Aim/Purpose of this Guideline 1.1.This guideline applies to clinical staff managing patients with spinal infections. Its aim is to help improve the timely diagnosis and initial treatment of vertebral osteomyelitis, discitis and spinal abscess of adult patients at RCHT. 2. The Guidance 2.1.Background Discitis is an increasingly common diagnosis. It is most common in the over 50 s with a 2:1 male to female ratio. It is more common with increasing age, more common with the increase use of interventional techniques (angiography, surgical interventions etc), and more common with intravenous drug use (hospital and illicit) Discitis, or vertebral osteomyelitis, is defined as infection of vertebral bones with extension into intervertebral discs. Most commonly, discitis occurs due to haematogenous spread (ie via blood from distant sites). However it can also be due to direct infection from spinal surgery or intra-abdominal infection. Due to the anatomical structure of segmental vertebral arteries it is common for two adjacent vertebrae to be affected The clinical presentation of discitis can be variable from acute back pain and fevers to slowly progressive back pain over a number of months. Other symptoms can include nerve root pain, motor and sensory changes in the limbs, and paralysis. On average it takes 48 days from initial symptom to diagnosis of discitis. It is therefore important not to discount the diagnosis because back pain has been present for some time Microbiology More than 50% of disicitis is due to Staphylococcus aureus. Infection may also be due to a wide range of other organisms including Gram negatives, Streptococci and Tuberculosis. Mixed infection is also possible. Blood cultures are only positive in 50-70% of patients with discitis. Blood cultures are most frequently positive when S. aureus is the infecting organism, though negative blood cultures do not rule out S. aureus as a cause Good outcomes in discitis are achieved with early diagnosis and appropriate, directed antimicrobial treatment. Delays in diagnosis or inappropriate antibiotics leads to increase need for surgical intervention, increase in chronic back pain and spinal deformity, and increase risk of paralysis. Page 1 of 9

2 2.2. Initial Management In patients with suspected discitis the following should be done immediately. See Figure If the patient is septic then treat as per the hospital sepsis guidelines (Link to sepsis guidelines?) in the first instance and ensure the following steps are taken as quickly as possible afterwards Blood cultures 3 sets, prior to any antibiotics Lab bloods including CRP MRI spine (whole spine discitis frequently occurs at multiple levels) Patient should have neurological examination documented in notes on admission and at least once a day until on appropriate antibiotics and clinically improving. Any deterioration in neurological status or development of new symptoms should lead to urgent re-imaging and discussion with microbiology and neurosurgeons CT guided biopsy (organised via neurosurgeons at Derriford Hospital). A biopsy should be performed in all patients prior to initiation of antibiotics unless there is a positive blood culture which fits the clinical picture or the patient is septic/unstable (see above). Discitis is treated for a minimum of 6 weeks. Response to empirical antibiotics, which are intravenous and broad spectrum, is therefore not a reason to avoid biopsy as identification of organism significantly changes antibiotic choice. Antibiotics for less than 1 week are unlikely to decrease sensitivity of the biopsy If the patient is stable antibiotics should be withheld until the diagnosis is confirmed (either by blood culture or positive biopsy result). An unstable or septic patient should be treated urgently after blood cultures are taken (as per sepsis guidelines). These patients must be discussed with the on call microbiologist. Page 2 of 9

3 Figure 1: Initial evaluation and treatment of discitis Page 3 of 9

4 2.3.Ongoing Management and monitoring. Once the diagnosis of discitis is confirmed, then the following should be considered Assess the patient for endocarditis. Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere. If there is a clinical possibility of endocarditis then the patient will need a Transoesphageal echocardiogram (TOE) - this will need to be organised via the Cardiologists. The patient will definitely require a TOE if the causative organism is S. aureus, whether or not there is clinical evidence of endocarditis Appropriate antibiotic treatment should continue for a minimum of six weeks and will be determined on a patient-by-patient basis with microbiology. Antibiotic choice is determined by causative organism so every effort must be made to determine this. If the patient requires a prolonged course of intravenous antibiotics then consider referring to Acute Care at Home team to organise intravenous antibiotics in the community Patients should mobilise with physiotherapy as pain allows. 2.4.Indications for surgery only a small number of patients with discitis will require any surgical intervention. The following may be indications for surgery. If any of these do occur then discuss with Derriford Neurosurgeons Progression of discitis despite appropriate antibiotics (rising CRP, worsening pain, new or progressive neurology etc) Threatened or actual cord compression due to vertebral collapse Epidural or paravertebral abscess requiring drainage 2.5. Long term follow up of patients with discitis should include review by the consultant in charge of the patient at the end of the course of antibiotics (likely to be in the outpatient setting). This should include assessment of pain and review of inflammatory markers. If pain is worsening or CRP is rising then this may indicate failure of antibiotic therapy. Repeat MRI may be required at this stage. Also further discussions with microbiology and neurosurgery to determine any further action. There is no routine indication for MRI in the follow up period for simple discitis as disc and vertebral body changes may remain for years 2.6.References Chenoweth, CE. Vertebral Osteomyelitis, Discitis and Spinal Epidural Abscess in Adults. Vertebral Osteomyelitis Guideline Team, University of Michigan, Quality Management Program (Figure 1 is adapted from these guidelines) Kowalski, TJ, Layton, KF, Berbari, EF, Steckelberg, JM, Huddleston PM, et al. Follow-up MRI Imaging in Patients with Pyogenic Spine Infections: Lack of Page 4 of 9

5 Correlation with Clinical Features. Am J Neuroradiol, Apr 2007; 28: McHenry, MC, Easley, KA, Locker, GA. Vertebral Osetomyelitis: Long-Term Outcome for 253 Patients from 7 Cleveland-Area Hospitals. Clin Infect Dis, 2002; 34,10: Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Diagnosis and management of each patient with discitis Dr Julia Bell, Dr Andree Evans Notes documentation Quarterly review of all patients coded with discitis Non compliance will be reported to the responsible medical team. Non compliance resulting in adverse patient outcome will be reported via DATIX Dr Julia Bell General Medicine and Eldercare Dr Andree Evans Microbiology Dr Richard Bendall - Microbiology Required changes to practice will be identified and actioned within each quarter review. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.3. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 5 of 9

6 Appendix 1. Governance Information Document Title Date Issued/Approved: February 2015 Clinical guidelines for the investigation and management of patients with discitis (vertebral osteomyelitis) Date Valid From: February 2015 Date Valid To: February 2018 Directorate / Department responsible (author/owner): Dr Julia Bell, Care of the Elderly Department Contact details: Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Clinical guidelines for the investigation and management of patients with discitis (vertebral osteomyelitis) Discitis, spinal infection, vertebral osteomyelitis, sepsis RCHT PCH CFT KCCG Rob Parry New Document Eldercare Dr Jon Stratton Not Required {Original Copy Signed} Internet & Intranet Eldercare Intranet Only Page 6 of 9

7 Related Documents: Training Need Identified? IDSA vertebral osteomyelitis guidelines No Version Control Table Date Versio n No Summary of Changes Changes Made by (Name and Job Title) Feb 2015 V1.0 New Policy All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 7 of 9

8 Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Directorate and service area: Is this a new or existing Policy? Name of individual completing assessment: 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* Telephone: 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Page 8 of 9

9 Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 9 of 9