Professional Documents
Culture Documents
Epidemiology and Outcomes of Infectious Spondylodi
Epidemiology and Outcomes of Infectious Spondylodi
DOI : 10.1097/BRS.0000000000002443
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
2
Department of Plastic and Reconstructive Surgery, Linkou Chang Gung Memorial Hospital, Chang
3
Center for Big Data Analytics and Statistics, Linkou Chang Gung Memorial Hospital, Chang Gung
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Correspondence:
Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital
E-mail: [email protected]
Fax: +886-(0)3-3282173
E-mail: [email protected]
The manuscript submitted does not contain information about medical device(s)/drug(s).
Chang Gung Memorial Hospital, Linkou (Grant CIRPD1D0031, CMRPG3B1353 and CORPG3C0152)
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Abstract
Study Design: A retrospective study of patients who were hospitalized for 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
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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-
Level of Evidence: 3
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
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
spondylodiscitis is elucidated.
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),
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
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
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
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-
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
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
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
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
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.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
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-
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
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
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
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Guidelines that are published by the Infectious Diseases Society of America suggest the initiation
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.
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
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
treatment critically predicts outcome. Hypotheses in this area must be tested in the future.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
In conclusion, MRSA was the most common pathogen and the lumbosacral spine was the most
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Reference
2. Akiyama T, Chikuda H, Yasunaga H, et al. Incidence and risk factors for mortality of vertebral
osteomyelitis: a retrospective analysis using the Japanese diagnosis procedure combination database.
from Japan with the most aging society. Eur Spine J 2011;20:649-54.
5. Prodromou ML, Ziakas PD, Poulou LS, et al. FDG PET is a robust tool for the diagnosis of
6. Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. J
7. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253
8. Karadimas EJ, Bunger C, Lindblad BE, et al. Spondylodiscitis. A retrospective study of 163
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
10. Faria B, Canto Moreira N, Sousa TC, et al. Spondylodiscitis in hemodialysis patients: a case
12. Mylona E, Samarkos M, Kakalou E, et al. Pyogenic vertebral osteomyelitis: a systematic review
14. Kang SJ, Jang HC, Jung SI, et al. Clinical characteristics and risk factors of pyogenic
15. Helewa RM, Embil JM, Boughen CG, et al. Risk factors for infectious spondylodiscitis in
17. System USRD. 2016 USRDS annual data report: Epidemiology of kidney disease in the United
States. In Bethesda ed: National Institutes of Health, National Institute of Diabetes and Digestive and
19. Berbari EF, Kanj SS, Kowalski TJ, et al. Executive Summary: 2015 Infectious Diseases Society
of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
20. Cornett CA, Vincent SA, Crow J, et al. Bacterial Spine Infections in Adults: Evaluation and
21. Yee DK, Samartzis D, Wong YW, et al. Infective spondylitis in Southern Chinese: a descriptive
22. Jeong SJ, Choi SW, Youm JY, et al. Microbiology and epidemiology of infectious spinal
23. Horino T, Sato F, Hosaka Y, et al. Predictive factors for metastatic infection in patients with
24. Park KH, Chong YP, Kim SH, et al. Clinical characteristics and therapeutic outcomes of
2013;67:556-64.
25. Kim CJ, Song KH, Jeon JH, et al. A comparative study of pyogenic and tuberculous
26. Perronne C, Saba J, Behloul Z, et al. Pyogenic and tuberculous spondylodiskitis (vertebral
27. Holland TL, Arnold C, Fowler VG, Jr. Clinical management of Staphylococcus aureus
28. Rutges JP, Kempen DH, van Dijk M, et al. Outcome of conservative and surgical treatment of
29. Cone LA, Hirschberg J, Lopez C, et al. Infective endocarditis associated with spondylodiscitis
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
30. Nucifora G, Badano LP, Viale P, et al. Infective endocarditis in chronic haemodialysis patients:
31. Oun HA, Price AJ, Traynor JP. Infective endocarditis in patients on haemodialysis - possible
32. Al-Nammari SS, Lucas JD, Lam KS. Hematogenous methicillin-resistant Staphylococcus
33. van Hal SJ, Jensen SO, Vaska VL, et al. Predictors of mortality in Staphylococcus aureus
34. Aagaard T, Roed C, Dahl B, et al. Long-term prognosis and causes of death after
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Figure 2 The survival graph to time of death and time of recurrence over the 1 year follow up
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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%)
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Table 3 Results of initial laboratory examination
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Table 4 Factors associated with mortality and recurrence within one year (univariate analysis)
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Table 5 Factors associated with mortality and recurrence within one year (multivariate analysis)
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.