SPINE An International Journal for the study of the spine, Publish Ahead of Print

DOI : 10.1097/BRS.0000000000002443

Epidemiology and Outcomes of Infectious Spondylodiscitis in Hemodialysis Patients

Yueh-An Lu, M.D.1*, Wei-Chiao Sun, M.D.1*, George Kuo, M.D.1, Chao-Yu Chen, M.D.1, Huang-Kai

Kao, M.D.2, YuJr Lin, M.S.3, Chia-Hui Lee, M.S.4, Cheng-Chieh Hung, M.D. Ph.D.1, Ya-Chung Tian,

M.D. Ph.D.1, Yu-Shien Ko, M.D. Ph.D.5#*, Hsiang-Hao Hsu, M.D. Ph.D.1#*

* Equal contribution

# Correspondence

Affiliations

1
Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Chang

Gung University, College of Medicine, Taoyuan, Taiwan

2
Department of Plastic and Reconstructive Surgery, Linkou Chang Gung Memorial Hospital, Chang

Gung University, College of Medicine, Taoyuan, Taiwan

3
Center for Big Data Analytics and Statistics, Linkou Chang Gung Memorial Hospital, Chang Gung

University, College of Medicine, Taoyuan, Taiwan

4
Department of Pharmaceutical Materials Management, Taoyuan Chang Gung Memorial Hospital,

Taoyuan, Taiwan

5
Division of Cardiology, Linkou Chang Gung Memorial Hospital, Chang Gung University, College of

Medicine, Taoyuan, Taiwan

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Correspondence:

Hsiang-Hao Hsu M.D. Ph.D.

Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital

No.5 Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan

E-mail: [email protected]

Phone: +886-(0)3-328-1200 ext. 8181

Fax: +886-(0)3-3282173

Yu-Shien Ko M.D. Ph.D.

Division of Cardiology, Linkou Chang Gung Memorial Hospital

No.5 Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan

E-mail: [email protected]

Phone: +886-(0)3-328-1200 ext. 8162 Fax: +886-(0)3-3271192

The manuscript submitted does not contain information about medical device(s)/drug(s).

Chang Gung Memorial Hospital, Linkou (Grant CIRPD1D0031, CMRPG3B1353 and CORPG3C0152)

funds were received in support of this work.

No relevant financial activities outside the submitted work.

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Abstract

Study Design: A retrospective study of patients who were hospitalized for infectious spondylodiscitis

over a 13 year period.

Objective: To elucidate the epidemiology and prognostic factors of infectious spondylodiscitis in

hemodialysis (HD) patients and to identify the impact of HD on infectious spondylodiscitis.

Summary of Background Data: Only a few case studies of infectious spondylodiscitis in HD patients

can be found in the literature. Reports of prognostic factors are limited and patients’ outcomes have not

been well described.

Methods: The cases of 1,402 patients who were hospitalized for infectious spondylodiscitis over a 13

year period were retrospectively reviewed. Of these, 102 patients on maintenance HD were enrolled in

this study. Cox’s proportional hazard model was used to evaluate the risk factors of mortality and

recurrence.

Results: The 102 enrolled patients had an average age 63.3±11.2 years old and male-to-female ratio of

1:1.04. Back pain was present in 75.5% of patients and the most commonly infected site was the

lumbosacral spine. Infection associated with vascular access was identified in 31.4% of patients. The

prevalence of dialysis via central venous catheters was higher than prevalent HD patients. Methicillin-

resistant S. aureus was the most common pathogen, followed coagulase-negative staphylococci. The

patients’ in-hospital survival rate was 82.4%; their vascular access survival rate was 75.5%; their one-

year survival rate was 78.4% and their one-year recurrence rate was 20.2%. Congestive heart failure

was associated with an increased one-year mortality. Other variables exhibited no significant

relationship with patients’ in-hospital mortality, one-year mortality or recurrence.

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Conclusions: The characteristics and outcomes of infectious spondylodiscitis in HD patients were

elucidated. Most of the demographic and clinical variables, evaluated upon admission, did not predict

mortality or recurrence.

Keywords: infectious spondylodiscitis, spondylitis, hemodialysis, end stage renal disease, blood-

stream infection, infectious disease, back pain, sepsis, epidemiology, outcome

Level of Evidence: 3

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Introduction

Infectious spondylodiscitis, defined as the pathogenic invasion of vertebra and intervertebral disc,

is an uncommon but serious disease. As the disease progresses, patients develop neurological deficits,

sepsis, and even mortality. The reported incidence of infectious spondylodiscitis in developed countries

is increasing1-4, probably owing to increased life expectancy, the popularity of spinal and percutaneous

invasive interventions and advanced diagnostic methods5,6. Microorganisms reach vertebra and

intervertebral discs in different ways, including antegrade bacteremia from the blood stream, retrograde

infection from the urinary tract and direct invasion from contiguous tissue or a surgical procedure.

Patients on maintenance hemodialysis (HD) have additional risk factors that contribute to blood stream

infection because of the repeated vascular puncturing, long-term catheter or Gore-Tex graft indwelling,

and contamination of dialysis water purification system. The characteristics and outcomes of infectious

spondylodiscitis in HD patients may be different from those in the general population.

Only a few case studies of infectious spondylodiscitis in HD patients can be found in the

literature. Reports of prognostic factors are limited, and patients’ outcomes have not been well

described. The goal of this study is to understand the epidemiology and prognostic factors that are

associated with infectious spondylodiscitis among HD patients. The effect of HD on infectious

spondylodiscitis is elucidated.

Materials and Methods

Patient Selection

The medical records of patients who were with infectious spondylodiscitis between January 2002

and August 2015 in a tertiary medical center were retrospectively reviewed. A total of 1,402 patients

were identified over a 13 year period. Infectious spondylodiscitis was diagnosed through clinical

presentations, image studies and results of microbiological tests. Magnetic resonance imaging (MRI),

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computed tomography (CT) and gallium inflammatory scan/bone scan were used for diagnostic

imaging. Of these patients, 107 had end-stage renal disease (ESRD) under long-term renal replacement

therapy. All of these patients were above 20 years of age. Patients who had received HD for fewer than

14 days (n=1) or who were on peritoneal dialysis (n=3) were excluded. A patient who was admitted for

recurrent spondylodiscitis (n=1) and had been previously treated in another hospital was also excluded.

One hundred and two patients were therefore enrolled (Fig 1). This study was approved by the

Institutional Review Board.

Characteristics and outcomes

Baseline characteristics of age, sex, primary cause of ESRD, comorbidities, HD duration and HD

access, were retrieved. Each patient’s presentation, location of infection, microbiological results, source

of infection, treatment and outcome were documented. The results of a blood examination upon

admission were recorded. The source of infection was obtained from the clinical course, and judged by

physicians. The pathogen was confirmed by isolating the microorganism from the spine or the abscess,

or from the blood of patients who yielded no positive tissue culture. Outcomes were evaluated at

discharge and 12 months from admission.

Statistical Analysis

Analysis was conducted using R 3.2.4 software (R Project for Statistical Computing, Vienna,

Austria). A two-sided p-value of 0.05 was considered to be statistically significant. The end points of

this study were in-hospital mortality, one-year mortality and one-year recurrence. The follow-up time

ended when patients died, or relapse, or were recurrence-free for one year. Descriptive statistics are

presented as mean ± standard deviation for continuous data and count (%) for categorical data. The

univariate and multivariate Cox proportional hazard models were used to estimate the risk factors for

mortality and recurrence. The missing values of C-reactive protein (CRP, n=2), erythrocyte

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sedimentation rate (ESR, n=34), alkaline phosphatase (Alk-P, n=29) and albumin (n=21) were

managed by multivariate imputation method. Variables that were significant in the univariate model

were used for adjustment in the multivariate model.

Results

Of 1,402 hospitalized patients with infectious spondylodiscitis, 102 under maintenance HD were

identified and enrolled in this study. Their mean age was 63.3±11.2 years old and their male-to-female

ratio was 1:1.04. Patient’s comorbidities are showed in table 1. Diabetic nephropathy (44.1%) and

chronic glomerulonephritis (35.3%) were two major causes of ESRD. The interval from HD initiation

to infectious spondylodiscitis varied from two weeks to 30 years; 27.5% of patients had received HD

for less than one year. The hemodialytic vascular access were arteriovenous fistula (AVF)- 47.1%,

arteriovenous graft (AVG)-18.6%, tunneled cuffed catheter (TCC)-27.5% and non-cuffed central

venous catheters (CVC)-6.9%. Forty-one patients (40.2%) undergone vascular access manipulation

(such as the insertion or removal of a catheter, percutaneous transluminal angioplasty, shunt creation or

reconstruction) in no more than six months before hospitalization. In patients with vascular access

infection associated infectious spondylodiscitis, 75.0% of patients had undergone manipulation of their

HD access.

The results herein indicate that 75.5% of patients presented back pain upon admission (Table 2).

Only 35.3% of patients had a fever. Lumbosacral spine (86.3%) was the most common site of infection,

followed by thoracic spine (12.7%) and cervical spine (8.8%). Four patients had skipping lesions that

involved two discontinuous infectious sites. Abscess formation was noted in 48.0% of patients. Two

patients had infectious spondylodiscitis that was combined with infective endocarditis (IE). In those

with IE, the pathogens were methicillin-resistant S. aureus (MRSA) in one patient and coagulase-

negative staphylococci (CoNS) in another patient.

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 Tissue or abscess biopsy/aspiration was performed in 65.7% of patients, and of those, 59.7%

yielded positive results (Table 2). Since Taiwan is an area of endemic tuberculosis, a tissue culture or

polymerase chain reaction of Mycobacterium tuberculosis was carried out. Blood culture was

performed for 91.2% of patients, of whom 65.6% yielded positive results. Four patients (3.9%) yielded

inconsistent results from blood and tissue cultures. Gram-positive cocci (GPC) were responsible for

66.7% of infections. MRSA was the most common pathogen (32.4%). CoNS (14.7%), methicillin-

susceptible S. aureus (8.8%), Klebsiella pneumoniae (2.0%), Serratia marcescens (1%), Candida

parasilosis (1%), Mycobacterium tuberculosis (1%) and Mycobacterium chelonae (1%) were also

identified. One patient yielded polymicrobial isolates.

Vascular access infection was associated with 31.4% of the cases of infectious spondylodiscitis in

HD patients. Spinal operation (7.8%), cellulitis (3.9%), urinary tract infection (2.0%) and contiguous

abscess (2.9%, psoas muscle abscess and deep neck infection) were found to be associated with

infectious spondylodiscitis. The primary focus of infection was unidentified in 52.0% of patients. We

did not note any case of intravenous drug user among the study group. Levels of

infection/inflammation markers and alkaline phosphatase, which are elevated in bony disease, were

documented upon admission (Table 3). To support diagnosis, the elevations of white blood cell count

(WBC), CRP, ESRAlk-P, and neutrophil/lymphocyte ratio (NLR) were noted in 52.9%, 99.0%, 91.1%,

38.4% and 82.4% of patients. The albumin level was 3.0±0.6 g/dL and 77.8% of patients had an initial

albumin level of less than 3.5 g/dL.

All patients received antibiotic therapy. The duration of antibiotic treatment was 59.0±43.5 days

(Table 2). Fifty-five patients (53.9%) underwent surgical treatment. Indications for surgical

intervention were spinal instability, progressive neurological deficit and disease progression despite

adequate antibiotic therapy. Operating methods included discectomy, laminectomy, and debridement of

the infected spine in all patients as well as anterior inter-body or posterolateral fusion of the spine with

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a bone graft and abscess drainage in selected patients. CT-guided drainage for an epidural, paraspinal

abscess or a psoas muscle abscess was conducted in 14.7% of patients. Vascular access was removed or

debrided in 75.0% of patients with a vascular access-associated infection. Sepsis was noted in 43.1% of

patients and 22.5% of patients developed septic shock. The in-hospital survival rate was 82.4% and the

hospital stay was 60.5±33.8 days. Of the surviving patients, 17 exhibited recurrence of infectious

spondylodiscitis within one year, yielding a one-year recurrence rate of 20.2%. The time from

discharge to recurrence was 106.2±91.9 days. The patients’ one-year survival rate was 78.4%. Causes

of death after discharge were sepsis in three patients (including one case of recurrent infectious

spondylodiscitis) and gastrointestinal bleeding-related hemorrhagic shock in one patient. The survival

graph to time of death and time of recurrence over the 1 year follow up is showed in figure 2.

Age, CHF, ESR and surgical treatment were associated with in-hospital mortality in the

univariate analysis (Table 4), but they were not significant in the multivariate analysis (Table 5). No

significant difference in in-hospital mortality was found between the S. aureus group and the non-S.

aureus group. Variables include comorbidities, location of infected site, presence of abscess, levels of

inflammation and infection markers, and type of vascular access was not independently associated with

in-hospital mortality. In the multivariate analysis of one-year mortality, CHF was significantly related

to one-year mortality (HR=2.99, CI=1.12-8.00, p=0.029). No demographic or clinical variables was

correlated with disease recurrence within one year. We evaluate the association between antibiotic

duration and recurrence in advance. After excluding patients who died of sepsis in the hospital, for each

incremental month of antibiotic treatment, the hazard ratio of disease recurrence rises by 0.25

(HR=1.25, CI=1.04-1.50, p=0.016).

Discussion

Over a 13 year period, 102 incident cases of infectious spondylodiscitis under maintenance HD

were diagnosed and treated in our hospital. ESRD patients accounted for 7.6% of all observed cases.

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Whereas males predominate in the non-HD cases2,7,8, gender difference was not significant in HD

patients9. Many patients presented prolonged back pain. This symptom can be mimicked by

degenerative spinal disease, which co-existed in 84.3% of the patients, delaying the diagnosis. Fever is

one of the most significant sign of infection but HD patients with infectious spondylodiscitis were often

afebrile. The same as patients who did not undergo dialysis1,4, the lumbosacral spine was the most

common site of infection, followed by the thoracic spine and the cervical spine in that order.

Infectious spondylodiscitis can be only be definitively diagnosed with a positive culture from the

infected spine or abscess. The tissue cultures yielded a 59.7% positive rate herein, which is consistent

with previous studies7,8,10-12. Blood culture also helped to identify pathogens, yielding 60-70% positive

results13. Although more than half of the patients were afebrile, bacteremia occurred in 65.6% of them.

At least two sets of blood cultures should be obtained before antibiotics are administered, even to

afebrile patients. Since 3.9% of patients yielded inconsistent blood and tissue culture results, bone or

abscess biopsy/aspiration should be considered in all patients in the absence of contraindication.

The primary focus of infection is often unrecognizable. Pre-existing or synchronous

genitourinary tract, skin and soft tissue, endocardium, intra-abdomen, or catheter-associated infection

were common sources of microorganisms 6,12,14. Vascular access infection was the most prevalent pre-

existing or synchronous infection in HD patients (31.4%). In the cases of vascular access-associated

infection, Staphylococci contributed to 87.5% of infections and the manipulation of vascular access

within six months was frequently noted. An invasive procedure or the establishment of vascular access

or CVC were major risk factors for infectious spondylodiscitis in HD patients10,15,16. In the US, 18.8%

of prevalent HD patients use catheter as dialysis access17. In our HD centers that served 1,550

outpatients, 10.82% of patients use catheter. TCC and non-cuffed CVC usage in this study (34.4%) is

relatively high. The formation of a biofilm on the catheter may be an important pathogenic mechanism.

Patients with TCC or non-cuffed CVC and those who underwent manipulation of vascular access

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within months should be regarded as being at high risk for infectious spondylodiscitis. Onset of

persistent back pain in a patient with a vascular catheter may be an indication for imaging and/or blood

work.

Leukocytosis and elevated inflammatory markers were detected. A trend toward normalization of

the levels of these markers may be indicators of a satisfactory response to treatment6. However, these

identifiable in the laboratory were not specific to a particular infectious disease. Appropriate image

studies might be performed to improve diagnostic accuracy. MRI is the recommend diagnostic tool,

with a high sensitivity that helps to distinguish among degenerative spondylitis, infectious

spondylodiscitis and malignancy related bony destruction13,18,19. CT scan, gallium inflammatory

scan/bone scan and positron emission tomography are also effective diagnostic methods5,20.

In the non-HD patients, S. aureus is responsible for 47.5-55.2% of infectious spondylodiscitis, and

is followed in that respect by streptococcal species, coagulase-negative staphylococci, Escherichia coli

and Pseudomonas aeruginosa1,4,8,12,14,21,22. Compared with non-HD patients, the incidence of

staphylococci infection, especially the methicillin-resistant strain, was higher in the HD cohort1,8,10,23,24.
14,25,26
Gram-negative bacilli (GNB) infection (2.9%) in HD patients occurred less frequently . This

microbiological difference was probably associated with the increased risk of staphylococci infection

and reduced risk or identification of urinary tract infection in HD patients. Patients without HD

dependence were classified as at low risk for S. aureus bacteremia27. For patients with S. aureus

bacteremia, delayed treatment and persistent fever predict the occurrence of metastatic infection, such

as that associated with infectious spondylodiscitis23. CoNS bacteremia in infectious spondylodiscitis

should be carefully considered as the actual pathogen, rather than as a contaminant. Fungus and

mycobacteria were rarely present. The incidence of tuberculous spondylitis was lower than that

reported in non-HD patients(13~33%) 8,21-23.

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 Guidelines that are published by the Infectious Diseases Society of America suggest the initiation

of empiric antimicrobial therapy in patients with hemodynamic instability, or severe or progressive

neurological symptoms19. Antibiotics should be withheld from clinically stable patients until pathogen

is obtained. The recommended treatment duration of antibiotics is six weeks28. Park et al. suggested an

extended antibiotic treatment duration of over eight weeks in cases of MRSA osteomyelitis because of

its associated high relapse rate24. Since MRSA and CoNS are common pathogens in HD patients,

vancomycin or teicoplanin alone or with one kind of anti-GNB antibiotic may be suitable in empiric

therapy. Longer antibiotic use is associated with disease recurrence and this may be an example of

reverse causality. While possible that long antibiotics might lead antibiotic resistance, more likely that

severe infections may need longer antibiotics treatment and more likely to recurrence.

The reported prevalence of combined IE in cases of infectious spondylodiscitis is 2.6~3.6%1,2,29.

IE in HD patients is mostly caused by S. aureus and CoNS30. In HD patients with IE, dialysis via TCC

or non-cuffed CVC contributed to a major risk of infection31. A heart murmur with GPC infectious

spondylodiscitis or S. aureus bacteremia may be a hint to initiate a survey for cardiac vegetation19.

HD was associated with increased in-hospital mortality of vertebral osteomyelitis patients2. The

reported mortality of HD patients with infectious spondylodiscitis was 33-46%9,16, which is higher than

non-HD patients (7.0-11.3%)7,8,14,21. Multi-comorbidities, incident chronic HD and a high incidence of

MRSA infection may contribute to this high mortality32,33. Age, diabetes, liver cirrhosis, malignancy

and IE were reported to be associated with in-hospital mortality 2. Aagaard et al. revealed that

neoplasms, cardiovascular diseases, alcohol abuse-related diseases and drug abuse-related diseases

increased long-term mortality after spondylodiscitis34. The present study demonstrates that most of the

demographic/clinical variables that are evaluated upon admission were statistically insignificant

predictors of survival or recurrence in HD patients. We suppose that an HD patient’s response to initial

treatment critically predicts outcome. Hypotheses in this area must be tested in the future.

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 This study has limitations. Cases were reviewed retrospectively so only associations between

mortality and recurrence factors could be identified, while causal relationships could not be. Since the

prevalence of infectious spondylodiscitis is low, the number of cases was limited, reducing our ability

to detect significance in variables. This study concerned a single center, and so may not be

representative of epidemiological results. Some of cases were not completely followed up for 1 year ( 7

less than 3 months and 15 less than 1 year). It is possible that patients recurred or died within 1 year

that were not reported. Despite these limitations, the clinical course, associated microorganisms, and

prognostic factors in HD patients with infectious spondylodiscitis were identified.

In conclusion, MRSA was the most common pathogen and the lumbosacral spine was the most

frequently infected area in HD patients with infectious spondylodiscitis. Blood cultures is

recommended even in afebrile patients. Tissue culture is suggested be obtained if no contraindication.

Since vascular access infection was the leading cause, patients use catheter for HD and those who

receive vascular access manipulation should be regarded as being at high risk. CHF was associated

with an increased one-year mortality. The results herein revealed that most of the demographic/clinical

variables upon admission did not predict a patient’s mortality or recurrence.

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Figure 1 Flow chart of patient selection

Patients hospitalized for infectious 
spondylodiscitis in 2002.01‐2015.08 (n=1,402)

Non‐dialysis patients (n=1,295)

Patient on dialysis (n=107)

Hemodialysis for < 14 days (n=1) 
Peritoneal dialysis (n=3)
Recurrent infectious spondylodiscitis (n=1)

102 patients were enrolled

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Figure 2 The survival graph to time of death and time of recurrence over the 1 year follow up

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 Table 1 Demographics of hemodialysis patients with infectious spondylodiscitis

Characteristics
Age, mean ± SD, year 63.3±11.2
Male gender, n (%) 50 (49.0%)
Comorbidity, n (%)
Degenerative spinal disease 86 (84.3%)
Hypertension 66 (64.7%)
Diabetes mellitus 48 (47.0%)
Coronary artery disease 23 (22.5%)
Congestive heart failure 16 (15.7%)
Cerebral vascular accident 12 (11.8%)
Cirrhosis 10 (9.8%)
Malignancy 6 (5.9%)
Immunosuppressive status 3 (2.9%)
Traumatic injury of spine 3 (2.9%)
Primary cause of end stage renal disease, n (%)
Diabetic nephropathy 45 (44.1%)
Chronic glomerulonephritis 36 (35.3%)
Malignant hypertension 3 (2.9%)
Gouty nephropathy 3 (2.9%)
Obstructive uropathy 2 (2.0%)
Urinary tract malignancy 1 (1.0%)
Polycystic kidney disease 4 (3.9%)
Drug 2 (2.0%)
Unknown 6 (5.9%)
Duration of HD, month 66.1±86.1
< 1 year, n (%) 28 (27.5%)
1-5 year, n (%) 24 (23.5%)
5-10 year, n (%) 26 (25.5%)
> 10 year, n (%) 16 (15.7%)
Unknown, n (%) 8 (7.8%)
Type of HD access, n (%)
arteriovenous fistula 48 (47.1%)
arteriovenous graft 19 (18.6%)
tunneled cuffed catheter 28 (27.5%)
Non-cuffed central venous catheters 7 (6.9%)
Access manipulation within 6 month, n (%) 41 (40.2%)
Vascular access associated 24/32 (75.0%)
Infection from other sources 3/17 (17.6%)
Unknown primary focus 14/53 (26.4%)

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 Table 2 Clinical characteristics and outcomes

Characteristics
Symptom at onset, n (%)
Back pain 77 (75.5%)
Fever 36 (35.3%)
Location, n (%)
Cervical spine 9 (8.8%)
Thoracic spine 13 (12.7%)
Lumbosacral spine 88 (86.3%)
Skipping lesion, n (%) 4 (3.9%)
Abscess formation, n (%) 49 (48.0%)
Combined with infective endocarditis, n (%) 2 (2.0%)
Culture result, n (%)
Tissue culture (biopsy/aspiration) positive 40/67 (59.7%)
Blood culture positive 61/93 (65.6%)
Uneven blood / tissue culture result 4 (3.9%)
Microbiology, n (%)
Gram-positive cocci 68 (66.7%)
Methicillin-susceptible S. aureus 9 (8.8%)
Methicillin-resistant S. aureus 33 (32.4%)
Coagulase-negative staphylococci 15 (14.7%)
Streptococcus spp. 2 (2.0%)
Enterococcus 8 (7.8%)
Corynebacterium sp. 1 (1.0%)
Gram-negative bacilli 3 (2.9%)
Klebsiella pneumoniae 2 (2.0%)
Serratiamarcescens 1 (1.0%)
Fungus 1 (1.0%)
Candida parasilosis 1 (1.0%)
Mycobacterium 2 (2.0%)
Mycobacterium tuberculosis 1 (1.0%)
Mycobacterium chelonae 1 (1.0%)
Polymicrobial isolates 1 (1.0%)
Unknown 27 (26.5%)
Source of infection, n (%)
Vascular access 32 (31.4%)
Spinal operation 8 (7.8%)
Cellulitis 4 (3.9%)
Urinary tract infection 2 (2.0%)
Contiguous abscess 3 (2.9%)
Unknown 53 (52.0%)
Treatment
Antibiotic treatment duration, days 59.0±43.5
Surgical treatment , n (%) 55 (53.9%)
CT-guided drainage, n (%) 15 (14.7%)
Access removal or debridement in vascular
24/32 (75%)
access associated infection, n (%)
Outcome
Sepsis, n (%) 44 (43.1%)
Shock, n (%) 23 (22.5%)
Hospital stay, day 60.5±33.8
In-hospital survival, n (%) 84 (82.4%)
Vascular access survival, n (%) 77 (75.5%)
1-year survival, n (%) 80 (78.4%)
1-year recurrence rate, n (%) 17/84 (20.2%)
Duration from discharge to recurrence, day 106.2±91.9

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 Table 3 Results of initial laboratory examination

Laboratory Examination mean ± SD Cut off point Percentage

White blood cell count 11,782.4±5,814.8 > 10,000 52.9%
cells/ml cells/ml
C-reactive protein 126.2±91.8 mg/mL > 5mg/mL 99.0%
Erythrocyte sedimentation 87.5±32.6 mm/hr > 30 mm/hr 91.1%
rate
Alkaline phosphatase 166.6±142.8 u/L > 140 u/L 38.4%
Neutrophil/lymphocyte ratio 12.6±11.8 >4 82.4%
Albumin 3.0±0.6 g/dL < 3.5 g/dL 77.8%

   

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 Table 4 Factors associated with mortality and recurrence within one year (univariate analysis)

Variable In-hospital mortality 1-year mortality 1-year recurrence

HR 95% CI p-value HR 95% CI p-value HR 95% CI p-value
Age 1.05 1.00-1.09 0.045 1.05 1.01-1.09 0.012 1.01 0.96-1.05 0.827
Male gender 1.02 0.39-2.66 0.972 1.56 0.67-3.66 0.302 1.46 0.54-3.91 0.455
Diabetes mellitus 0.92 0.35-2.43 0.867 0.96 0.42-2.22 0.926 2.75 0.95-7.92 0.061
Hypertension 0.71 0.26-1.97 0.515 1.17 0.48-2.87 0.733 1.16 0.40-3.33 0.786
Coronary artery disease 1.73 0.63-4.69 0.285 1.71 0.70-4.18 0.244 1.60 0.56-4.61 0.384
Congestive heart failure 2.67 1.01-7.09 0.048 4.44 1.89-10.43 0.001 0.39 0.05-2.99 0.368
Cerebral vascular accident 1.16 0.33-4.13 0.820 1.17 0.35-3.97 0.795 0.46 0.06-3.48 0.452
Cirrhosis 0.71 0.09-5.37 0.739 0.41 0.05-3.03 0.381 - - -
Malignancy - - - - - - 0.87 0.11-6.56 0.889
Immunosuppressive status 2.69 0.35-20.89 0.343 4.67 1.09-20.00 0.038 - - -
Traumatic injury of spine - - - - - - - - -
Degenerative spinal disease 0.54 0.19-1.57 0.260 0.34 0.14-0.83 0.018 0.45 0.14-1.40 0.167
Primary cause of ESRD- 1.02 0.38-2.70 0.972 1.10 0.47-2.54 0.827 2.38 0.87-6.56 0.093
DM nephropathy
Dialysis access-AVG vs. AVF 0.24 0.03-1.92 0.180 0.61 0.17-2.17 0.442 0.45 0.10-2.07 0.304
Dialysis access-TCC vs. AVF 0.67 0.23-1.97 0.469 0.89 0.33-2.42 0.825 0.68 0.21-2.22 0.525
Dialysis access-FDL vs. AVF 0.36 0.05-2.89 0.339 1.15 0.26-5.21 0.852 0.62 0.08-4.89 0.649
Access surgery within 6 months 0.63 0.24-1.70 0.364 1.22 0.53-2.83 0.640 0.64 0.22-1.83 0.401
Fever 0.62 0.20-1.91 0.404 0.83 0.34-2.05 0.691 1.06 0.39-2.92 0.909
Back pain 0.41 0.16-1.07 0.068 0.29 0.13-0.67 0.004 0.84 0.27-2.62 0.769
Cervical spine 2.71 0.77-9.47 0.119 1.89 0.56-6.39 0.305 - - -
Thoracic spine 0.44 0.09-2.08 0.299 1.52 0.51-4.50 0.448 0.42 0.06-3.19 0.402
Lumbosacral spine 0.50 0.17-1.49 0.212 0.35 0.14-0.90 0.029 2.08 0.27-15.76 0.478
Skip lesion - - - - - - - - -
Abscess 0.40 0.14-1.15 0.089 0.58 0.24-1.37 0.213 3.39 1.09-10.52 0.034
Infective endocarditis 0.00 0.00-Inf 0.998 - - - - - -
Pathogen-S.aureus 0.57 0.21-1.53 0.265 1.14 0.49-2.64 0.762 1.98 0.74-5.32 0.176
Vascular access associated 0.98 0.37-2.61 0.974 1.87 0.81-4.34 0.143 0.74 0.24-2.28 0.596
White blood cell count 0.97 0.88-1.07 0.531 1.00 1.00-1.00 0.836 1.00 1.00-1.00 0.010
C-reactive protein 1.00 0.99-1.00 0.909 1.00 1.00-1.00 0.984 1.00 1.00-1.01 0.050
Erythrocyte sedimentation rate 0.99 0.98-1.00 0.022 0.99 0.98-1.00 0.191 1.01 1.00-1.02 0.114
Alkaline phosphatase 1.00 0.99-1.00 0.382 1.00 1.00-1.00 0.921 1.00 1.00-1.00 0.283
Albumin 0.70 0.30-1.62 0.400 0.63 0.32-1.24 0.184 1.11 0.52-2.34 0.789
Neutrophil/lymphocyte ratio 0.99 0.95-1.03 0.618 1.01 0.98-1.04 0.414 1.03 1.00-1.06 0.055
Antibiotic duration 0.93 0.09-0.97 0.000 0.99 0.98-1.01 0.446 1.01 1.00-1.01 0.017
Antibioticduration (Drop 1.25 1.04-1.50 0.016
hospital death, month)
Surgical treatment 0.29 0.10-0.81 0.019 0.29 0.11-0.73 0.009 1.29 0.47-3.54 0.627
CT-guided drainage - - - 0.51 0.12-2.18 0.362 1.83 0.59-5.67 0.297

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 Table 5 Factors associated with mortality and recurrence within one year (multivariate analysis)

Population Variable HR 95% CI p-value C-index

In-hospital mortality Age 1.03 0.98-1.08 0.293 0.658
Congestive heart failure 1.61 0.53-4.93 0.404
Erythrocyte sedimentation rate 0.99 0.98-1.00 0.112
Surgical treatment 0.46 0.13-1.70 0.245

One-year mortality Age 1.04 0.99-1.08 0.118 0.769

Congestive heart failure 2.99 1.12-8.00 0.029
Immunosuppressive status 3.91 0.790-19.33 0.095
Degenerative spinal disease 0.41 0.16-1.05 0.063
Back pain 0.67 0.24-1.82 0.429
Lumbosacral spine 0.36 0.13-1.00 0.050
Surgical treatment 0.70 0.21-2.31 0.560

One-year recurrence Abscess 2.37 0.71-7.93 0.163 0.727

White blood cell count 1.06 0.99-1.15 0.102
C-reactive protein 1.00 1.00-1.01 0.431
Antibiotic duration 1.00 1.00-1.01 0.288

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