BACKGROUND
Biopsy specimens are often obtained in the evaluation of hematogenous vertebral osteomyelitis. The effect of prebiopsy antibiotic exposure on pathogen recovery is unknown.


METHODS
We conducted a retrospective cohort study of adult inpatients with hematogenous vertebral osteomyelitis at a tertiary care hospital from 1 January 2003 through 31 July 2007. Antibiotic exposure within 14 days before biopsy was evaluated.


RESULTS
Of 150 patients with hematogenous vertebral osteomyelitis, 92 (61%) underwent a biopsy (60 [65%] needle and 32 [35%] open biopsies). The median time from admission to biopsy was 3 days (range, 0-69 days). Patients who underwent biopsy were more likely to have weakness (53 [58%] biopsy vs 15 [26%] no biopsy; P<.001) and sensory loss (27 [29%] vs 6 [10%]; P=.006), but were less likely to have a positive blood culture result (28 [30%] vs 30 [52%]; P=.01). Pathogens were recovered in 61 patients (66%). Open biopsy had a higher yield than needle biopsy (29 [91%] of 32 vs 32 [53%] of 60; P<.001). Sixty patients (65%) who had biopsies performed received antibiotics ≤14 days before the procedure (median duration, 4 days; range, 1-37 days). Open biopsy predicted positive biopsy culture results (adjusted odds ratio, 8.4; 95% confidence interval, 2.2-31.8), but there was no association of prebiopsy antibiotics with culture results (adjusted odds ratio, 2.3; 95% confidence interval, 0.8-6.2).


CONCLUSIONS
A pathogen was recovered from 61 (66%) of 92 patients who had biopsies performed in this cohort of hematogenous vertebral osteomyelitis. Open biopsies had a higher microbiological yield than did needle biopsies. Antibiotic exposure before biopsy did not negatively impact pathogen recovery and should not be the sole reason for foregoing biopsies.

The Impact of Pre-Biopsy Antibiotics on Pathogen Recovery in Hematogenous Vertebral Osteomyelitis

Drug Hepatotoxicity: Newer Agents.

Diagnosis of spondylodiscitis (SD) may be challenging due to the nonspecific clinical and laboratory findings and the need to perform various diagnostic tests including serologic, imaging, and microbiological examinations. Homogeneous management of SD diagnosis through international, multidisciplinary guidance would improve the sensitivity of diagnosis and lead to better patient outcome. An expert specialist team, comprising nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), neuroradiologists appointed by the European Society of Neuroradiology (ESNR), and infectious diseases specialists appointed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), reviewed the literature from January 2006 to December 2015 and proposed 20 consensus statements in answer to clinical questions regarding SD diagnosis. The statements were graded by level of evidence level according to the 2011 Oxford Centre for Evidence-based Medicine criteria and included in this consensus document for the diagnosis of SD in adults. The consensus statements are the result of literature review according to PICO (P:population/patients, I:intervention/indicator, C:comparator/control, O:outcome) criteria. Evidence-based recommendations on the management of adult patients with SD, with particular attention to radiologic and nuclear medicine diagnosis, were proposed after a systematic review of the literature in the areas of nuclear medicine, radiology, infectious diseases, and microbiology. A diagnostic flow chart was developed based on the 20 consensus statements, scored by level of evidence according to the Oxford Centre for Evidence-based Medicine criteria. This consensus document was developed with a final diagnostic flow chart for SD diagnosis as an aid for professionals in many fields, especially nuclear medicine physicians, radiologists, and orthopaedic and infectious diseases specialists.

/pdf/joint-eanm-esnr-and-escmid-endorsed-consensus-document-for-1kyx4ererk.pdf

Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults.

The goal of this review is to provide an update on the epidemiology, diagnosis, and treatment of opportunistic fungal infections in patients with human immunodeficiency virus (HIV) infection including Cryptococcus spp., Histoplasma spp., Coccidioides spp., and Talaromyces marneffei, formerly Penicillium marneffei. In many settings, despite increasing roll out of antiretroviral therapy (ART), opportunistic invasive mycoses produce a substantial burden of disease. The prevalence of specific fungal pathogens depends on their endemicity. Viral suppression achieved by greater access to ART and increased the availability of point-of-care testing with rapid diagnostic tests (RDTs) aid to curtail the associated fungi morbidity. RDTs allow earlier screening to preemptively initiate treatment of opportunistic fungal pathogens. Identifying asymptomatic cryptococcal infection before starting ART is crucial in reducing the risk of the immune reconstitution inflammatory syndrome (IRIS). There is an urgent need to decrease the burden of opportunistic invasive fungal infections in individuals with HIV/AIDS through different interventions: (a) continue to expand the deployment of ART to the most affected populations to achieve viral suppression; (b) ensure early diagnosis of fungal pathogen with point-of-care testing; (c) improve fungal diagnostic capacity in areas with the highest burden of AIDS-related mycoses; and (d) increased availability of existing antifungal drugs to optimally treat these infections.

Opportunistic Invasive Mycoses in AIDS: Cryptococcosis, Histoplasmosis, Coccidiodomycosis, and Talaromycosis.

It is estimated that fungal infections cause 1 million deaths annually, accounting for 50% of all AIDS-related deaths [1]. In this specific patient group, data from 2009 revealed that fungal meningitis is responsible for approximately 500,000 deaths each year [2].

The most common fungal pathogen infecting the brain is Cryptococcus neoformans, a yeast-like pathogen that is highly efficient in causing damage to immunosuppressed human hosts [3]. The fungus, which is widespread in the environment, primarily reaches the lung after inhalation of environmental cells and disseminates to the brain in the immunosuppressed host. Clinical studies in humans in combination with animal models of neurological cryptococcosis enabled the classification of the disease into different syndromes, including meningitis, encephalitis, meningoencephalitis, ventriculitis, increased intracranial pressure, and space-occupying lesions [3]. According to the Centers for Disease Control and Prevention (CDC) of the United States, cryptococcal meningitis is a global problem. Estimates by Park and colleagues indicated that approximately 957,900 cases (range, 371,700–1,544,000) of cryptococcal meningitis occur each year, resulting in 624,700 deaths (range, 125,000–1,124,900) by three months after infection [2]. Currently, estimates of global disease burden, including disability-adjusted life year (DALY), are not available, since cryptococcosis is not separately reported. Most cases are opportunistic infections that occur among people with HIV/AIDS.

Although the widespread availability of antiretroviral therapy (ART) in developed countries has helped reduce cryptococcal infections in these areas, it is still a major problem in developing countries where access to healthcare is limited. Throughout much of sub-Saharan Africa, for example, Cryptococcus is now the most common cause of adult meningitis, which may kill as many people each year as tuberculosis [2]. The high fatality rate, especially in developing countries, stems from late diagnosis, access only to the least effective treatments, and from drug resistance when treated.

/pdf/funding-and-innovation-in-diseases-of-neglected-populations-1k9yyqr7m9.pdf

Funding and Innovation in Diseases of Neglected Populations: The Paradox of Cryptococcal Meningitis.

Cryptococcosis is a fungal disease caused by Cryptococcus neoformans and Cryptococcus gattii. By inhalation and subsequent pulmonary infection, it may disseminate to the CNS and cause meningitis or meningoencephalitis. Most cases occur in immunosuppressed hosts, including patients with HIV/AIDS, patients receiving immunosuppressing drugs, and solid organ transplant recipients. However, cryptococcosis also occurs in individuals with apparently healthy immune systems. A growing number of cases are caused by C gattii, with infections occurring in both immunosuppressed and immunocompetent individuals. In the majority of documented cases, treatment of C gattii infection of the CNS requires aggressive management of raised intracranial pressure along with standard antifungal therapy. Early cerebrospinal fluid evacuation is often needed through placement of a percutaneous lumbar drain or ventriculostomy. Furthermore, pharmacological immunosuppression with a high dose of dexamethasone is sometimes needed to ameliorate a persistently increased inflammatory response and to reduce intracranial pressure. In this Grand Round, we present the case of an otherwise healthy adolescent female patient, who, despite aggressive management, succumbed to C gattii meningoencephalitis. We also present a review of the existing literature and discuss optimum clinical management of meningoencephalitis caused by C gattii.

/pdf/management-of-cryptococcus-gattii-meningoencephalitis-2ojwgn6o4h.pdf

Management of Cryptococcus gattii meningoencephalitis

Introduction: Infectious vertebral osteomyelitis (VO) is a significant source of morbidity that can lead to chronic sequelae. The objectives of this study were to describe the clinical presentations and assess the outcomes of VO. Methods: A retrospective review of cases of VO admitted to an inpatient service between 1 January 2000 and 31 March 2012 was carried out. Cases had evidence of VO by clinical syndrome, imaging, histopathology, and/or microbiology. Outcomes assessed were implantation of prosthetic material for stabilization, hospital readmission for management of VO, repeat surgical intervention, and additional or prolonged courses of antibiotics. Results: Of 117 VO cases, a causative organism was identified in the majority (88.0%). Staphylococcus aureus was the most common organism isolated, followed by Streptococcus species. The most common infection site was the lumbar spine (55.5%). Surgical intervention was required in 81.2% of cases. Infections involving the lumbar vertebrae were ass...

Vertebral osteomyelitis: retrospective review of 11 years of experience.

Pseudozyma spp are amorphic yeasts. They are commonly plant pathogens, but rarely cause invasive fungal disease in humans. Only three cases of central venous catheter (CVC)-associated blood stream infections due to this organism have been reported in the literature. Main underlying risk factors for Pseudozyma spp infection are bowel surgery, CVC and total parenteral nutrition. We present a rare case of Pseudozyma spp catheter-associated blood stream infection that was successfully treated with antifungal therapy and removal of CVC. It is important to recognise and differentiate this species from other yeasts as it may require the use of amphotericin B or voriconazole instead of fluconazole, to which the organism is variably resistant.

/pdf/pseudozyma-spp-catheter-associated-blood-stream-infection-an-2a2mamf3iy.pdf

Pseudozyma spp catheter-associated blood stream infection, an emerging pathogen and brief literature review.

/pdf/rare-case-of-rilpivirine-induced-severe-allergic-hepatitis-bjy7isnbsu.pdf

Wajid Siddiqui

Papers

Management of Cryptococcus gattii meningoencephalitis

Vertebral osteomyelitis: retrospective review of 11 years of experience.

Pseudozyma spp catheter-associated blood stream infection, an emerging pathogen and brief literature review.

Rare case of rilpivirine-induced severe allergic hepatitis

Clostridium difficile: case report and concise review of fecal microbiota transplantation.