Treatment of Pediatric Spondylodiscitis
In children with spondylodiscitis, initiate empirical broad-spectrum antibiotic therapy with vancomycin combined with a third- or fourth-generation cephalosporin or carbapenem for 2-4 weeks intravenously, followed by oral antibiotics to complete 6-12 weeks total duration, reserving surgery only for neurological deficits or spinal instability. 1
Initial Antibiotic Regimen
The empirical antibiotic approach must cover both methicillin-resistant Staphylococcus aureus (MRSA) and gram-negative organisms, as S. aureus is the most common pathogen in pediatric spondylodiscitis 2, 3. Start vancomycin (15-20 mg/kg IV every 12 hours) combined with one of the following: 1
- Cefepime (2 g IV every 8-12 hours), OR
- Carbapenem: meropenem (1 g IV every 8 hours), imipenem-cilastatin (500 mg IV every 6 hours), or ertapenem (1 g IV every 24 hours), OR
- Ceftriaxone (2 g IV every 24 hours) + metronidazole (500 mg IV every 8 hours) 1
Critical pitfall to avoid: Delaying adequate treatment while awaiting culture results leads to worse outcomes—approximately 27% of patients in one study did not receive appropriate coverage until cultures returned 4. Broad-spectrum coverage is essential from the outset 2, 4.
Duration of Treatment
Administer initial parenteral therapy for 2-4 weeks, then transition to oral antibiotics to complete 6-12 weeks total treatment duration. 1 A randomized trial demonstrated that 6 weeks total treatment is non-inferior to 12 weeks, with 90.9% clinical cure rates in both groups 1. In pediatric cohorts, median treatment duration of 12 weeks has been effective without clinical sequelae, even in patients with comorbidities 2.
Switch to oral therapy when: 5
- C-reactive protein (CRP) has decreased
- Significant epidural or paravertebral abscesses have been drained (if present)
- Clinical improvement is evident
Use oral antibiotics with excellent bioavailability (fluoroquinolones, linezolid, metronidazole); avoid oral β-lactams for initial treatment due to poor bioavailability 5.
Diagnostic Considerations Before Treatment
Obtain blood cultures and consider CT-guided biopsy before initiating antibiotics when feasible. 1 Biopsy-guided or surgical biopsy has higher diagnostic yield than blood cultures alone 1. However, in pediatric patients, invasive procedures should be reserved for specific situations 6:
- Empirical antibiotics associated with worsening spinal damage on MRI
- Vertebral lesion mimics a tumoral process
- Tuberculosis or fungal infection suspected but not confirmed 5
Exclude tuberculosis using tuberculin skin testing and Quantiferon TB-gold tests, particularly in endemic areas 6, 3.
Monitoring and Follow-Up
Monitor erythrocyte sedimentation rate (ESR) and CRP as primary means to evaluate treatment response. 1, 7 MRI remains the gold standard for both diagnosis (96% sensitivity, 94% specificity) and monitoring therapy efficacy 1, 6.
Perform follow-up MRI when: 5
- Persistent bacteremia occurs
- Lack of clinical response to treatment
- Diagnostic delay exceeded 2 months (associated with multivertebral involvement and complications) 2
CT is useful for evaluating complications in patients with spinal instrumentation or when MRI is contraindicated 7.
Age-Specific Clinical Presentations
Recognize that clinical presentation varies significantly by age: 2
- Children <4 years: Refusal/inability to sit or bear weight, irritability, limping, poor general condition—fever and back pain may be absent 6, 2
- Children ≥4 years: Back pain, fever, and tenderness upon spinal palpation are more common 2
Median diagnostic delay is 12 days, and delays >2 months are consistently associated with multivertebral involvement and complications 2.
Surgical Indications
Surgery is indicated only in specific circumstances: 1
- Neurological deficits with spinal cord compression
- Progressive spinal deformities
- Failure of conservative therapy with insufficient pain relief
- Unreliable pathogen identification requiring debridement for sampling
- Spinal instability
In pediatric cohorts, surgical treatment was required in only 3-4% of cases, specifically those with neurologic involvement 2. Conservative management with antibiotics and spinal immobilization is effective in the vast majority of pediatric cases 3.
Special Considerations
Approximately 10% of cases present with non-contiguous multilevel infections, which should be considered during diagnostic evaluation and follow-up 1, 7. Single-level infection occurs in 65% of patients, while contiguous multilevel infection occurs in approximately 20% 1.
The lumbar spine is most frequently involved, and more than one vertebra is commonly affected in pediatric cases 2. Laboratory values may be normal or only slightly abnormal, particularly in younger children with subacute or chronic presentations 6.