ESPONDILODISCITIS PIÓGENA: FACTORES DE RIESGO PARA FRACASO TERAPÉUTICO Y RECURRENCIA

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

Brasil

Español English

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

ESPONDILODISCITIS PIÓGENA: FACTORES DE RIESGO PARA FRACASO TERAPÉUTICO Y RECURRENCIA

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN:

Objetivo:

Evaluar los factores pronósticos asociados con el fracaso terapéutico y la recurrencia en la espondilodiscitis piógena (EP).

Métodos:

Se realizó un estudio de cohorte histórica en un hospital de referencia brasileño para enfermedades del aparato locomotor y del neurodesarrollo. Se incluyeron todos los pacientes con EP tratados entre enero de 1999 y diciembre de 2018 y seguidos durante al menos un año. La EP se definió en base a criterios clínicos, de laboratorio y radiológicos. También se recopilaron y analizaron los datos microbiológicos y los resultados clínicos al final del tiempo de seguimiento.

Resultados:

Se incluyeron 50 pacientes (edad media 50,94 ± 15,84 años, sexo masculino 76,00%). A los doce meses de seguimiento, se observó fracaso terapéutico en el 24,00% (n=12) y recurrencia en el 18,00% (n=09) de los pacientes. Entre los que se curaron, se encontraron síntomas residuales en el 50,00% (19/38). No se observaron muertes. Tras el análisis multivariante, el fracaso terapéutico se asoció a la prescripción de antibioticoterapia antes de los resultados del cultivo (p = 0,0153), compresión medular (p = 0,0053) y déficits sensitivos (p = 0,0341). Además, la recurrencia se asoció con cirugías previas no espinales (p = 0,0350) y compresión medular (p = 0,0447).

Conclusión:

La EP causa una morbilidad significativa. El pronóstico depende principalmente de la presentación clínica al ingreso, especialmente de la existencia de compresión medular, lo que refuerza la importancia del diagnóstico precoz. Nivel de Evidencia II; Estudios de Pronóstico.

Descriptores:
Discitis; Pronóstico; Resultado del Tratamiento

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