What is the next best step in managing a hemodynamically stable, afebrile patient with vertebral osteomyelitis and discitis at L3-L4, without epidural abscess or neurological deficits?

From the Guidelines

The next best step is to hold antibiotics and get CT guided biopsy for cultures. In a patient with vertebral osteomyelitis and discitis without neurological deficits or hemodynamic instability, obtaining a microbiological diagnosis before starting antibiotics is crucial for targeted therapy. A CT-guided biopsy allows identification of the causative organism, which guides appropriate antibiotic selection. Starting empiric antibiotics before obtaining cultures significantly reduces the yield of microbiological diagnosis and may lead to prolonged courses of potentially ineffective antibiotics. Since the patient is stable without signs of sepsis, neurological compromise, or epidural abscess, there is time to perform the biopsy safely before initiating treatment. Once cultures are obtained, appropriate antibiotics can be started based on the identified pathogen and its susceptibilities, typically requiring 6-8 weeks of therapy. This approach ensures optimal treatment outcomes and reduces the risk of treatment failure or relapse, as recommended by the Infectious Diseases Society of America (IDSA) guidelines 1. The use of imaging studies such as MRI and CT scans can help guide the biopsy and assess the extent of the infection, but the IDSA guidelines emphasize the importance of obtaining a microbiological diagnosis before starting treatment 1. By following this approach, the patient's morbidity, mortality, and quality of life can be optimized. Some key points to consider include:

• The patient's stability and lack of neurological deficits or hemodynamic instability allow for a delayed start of antibiotics until cultures are obtained.
• The importance of obtaining a microbiological diagnosis to guide targeted antibiotic therapy.
• The potential risks of starting empiric antibiotics before obtaining cultures, including reduced yield of microbiological diagnosis and prolonged courses of potentially ineffective antibiotics.
• The role of imaging studies in guiding the biopsy and assessing the extent of the infection.

From the Research

Next Best Step

The patient has been diagnosed with vertebral osteomyelitis and discitis at L3-L4, and there is no epidural abscess. The next best step would be to:

• Start IV antibiotics, as the patient has a confirmed infection 2
• Obtain a CT-guided biopsy for cultures to identify the causative microorganism, as blood cultures are frequently negative in patients with vertebral discitis-osteomyelitis 3
• Consider holding antibiotics for 1-2 weeks before biopsy if clinically feasible, but biopsy can still be performed without stopping antimicrobial therapy if needed 3

Rationale

• Starting IV antibiotics is crucial to treat the infection and prevent further complications 2
• Obtaining a CT-guided biopsy for cultures is essential to identify the causative microorganism and guide targeted antimicrobial therapy 3
• The yield of CT-guided percutaneous sampling is 31-91%, which is lower than the reported yield of open biopsy, but the less invasive approach may be favored given its relative safety and low cost 3

Considerations

• The patient's condition is stable, and there is no bowel/bladder dysfunction, which suggests that immediate surgical intervention may not be necessary 4
• The patient's age and underlying health conditions should be taken into account when deciding on the best course of treatment 2
• The results of the biopsy and culture will guide the further management of the patient's infection 3, 5