Bacteroides fragilis vertebral osteomyelitis: case report and a review of the literature.Background: To review the presentation of Bacteroides fragilis Bacteroides frag·i·lis n. A bacterium that is one of the predominant microorganisms in the lower intestinal tract of humans. Bacteroides fragilis (B fragilis) spondylodiscitis. Methods: Two investigators independently searched the published English, Spanish and French languages literature through September 2005 using MEDLINE The online medical database of the U.S. National Library of Medicine (NLM) whose parent is the National Institutes of Health, Bethesda, MD. MEDLINE contains millions of articles from thousands of medical journals and publications. The consumer section of the site (http://medlineplus. (1966-2005). We included all reported cases of vertebral ver·te·bral adj. 1. Of, relating to, or of the nature of a vertebra. 2. Having or consisting of vertebrae. 3. Having a spinal column. osteomyelitis osteomyelitis (ŏs'tēōmī'əlī`tĭs), infection of the bone and bone marrow. Direct infection of bone usually occurs through open fractures, penetrating wounds, or surgical operations. or spondylodiscitis caused by B fragilis, not related to sacral sacral /sa·cral/ (sa´kral) pertaining to the sacrum. sa·cral adj. In the region of or relating to the sacrum. sacral, adj pertaining to the sacrum. decubitus ulcers Decubitus ulcers A pressure sore resulting from ulceration of the skin occurring in persons confined to bed for long periods of time Mentioned in: Immobilization , in adults (age 16 yr and above). A third author independently reviewed all articles and extracted data for accuracy. The final pool of eligible publications included 11 articles, publication dates ranging from 1978 to 2005. Eight were written in English, two in Spanish, and one in French. Results: The age of the patients in this series ranged from 17 to 74 years, with a mean age of 55 years. Male to female ratio was 6:1. Lumbar involvement was reported in nine cases, thoracic involvement in two patients and sacral involvement in one patient. B fragilis was recovered by blood culture in four patients and by tissue culture in eight patients. Metronidazole metronidazole /met·ro·ni·da·zole/ (-ni´dah-zol) an antiprotozoal and antibacterial effective against obligate anaerobes; used as the base or the hydrochloride salt. It is also used as a topical treatment for rosacea. was the most common antibiotic used for treatment (eight patients), either as monotherapy or in combination with other antibiotics. Conclusions: B fragilis is a rare causative agent of spondylodiscitis, but it should be considered in patients with spondylodiscitis who have contiguous intraabdominal or pelvic infections or who had recent gastrointestinal procedures that may have led to B fragilis bacteremia bacteremia: see septicemia. bacteremia Presence of bacteria in the blood. Short-term bacteremia follows dental or surgical procedures, especially if local infection or very high-risk surgery releases bacteria from isolated sites. . Key Words: Bacteroides fragilis, vertebral osteomyelitis, spondylodiscitis, anaerobic bacteria Anaerobic bacteria Bacteria that do not require oxgyen, found in low concentrations in the normal vagina Mentioned in: Aminoglycosides, Bacterial Vaginosis, Flesh-Eating Disease, Periodontal Disease ********** Aerobic bacteria, Mycobacterium tuberculosis, and candida species are the usual pathogens of vertebral osteomyelitis (spondylodiscitis), with anaerobic bacteria rarely causing this type of infection. (1-6) We report a case of vertebral spondylodiscitis and epidural epidural /epi·du·ral/ (-dur´il) situated upon or outside the dura mater. ep·i·du·ral adj. Located on or over the dura mater. n. abscess abscess, localized inflamation associated with tissue necrosis. Abscesses are characterized by inflamation, which is due to the accumulation of pus in the local tissues, and often painful swelling. caused by Bacteroides fragilis (B fragilis) and review similar cases found in the literature. Case Report A 58-year-old diabetic male with a history of chronic low back pain and end-stage renal disease End-stage renal disease (ESRD) Total kidney failure; chronic kidney failure is diagnosed as ESRD when kidney function falls to 5-10% of capacity. Mentioned in: Chronic Kidney Failure end-stage renal disease on dialysis presented with a three week history of worsening lower back pain not relieved with his usual pain medication or positional change. The patient denied lower extremity paresthesias Paresthesias A prickly, tingling sensation. Mentioned in: Autoimmune Disorders , urinary or fecal incontinence, fever or chills. He had no previous history of trauma or back surgery. Recent past medical history included an incision and drainage Incision and drainage is a minor surgical procedure to release pus or pressure built up under the skin, such as from an abscess or boil. It is performed by treating the area with an antiseptic, such as iodine based solution, and then making a small incision to puncture the skin of a perianal abscess nine months prior, with apparent resolution. No cultures were obtained at that time. Six months after the incision and drainage, the patient complained of increased lumbar back pain. A lumbar-sacral x-ray and a lumbar spine MRI 1. (application) MRI - Magnetic Resonance Imaging. 2. MRI - Measurement Requirements and Interface. obtained at that visit were normal. The current presentation physical examination was notable for normal vitals vi·tals pl.n. 1. The vital body organs. 2. The parts that are essential to continued functioning, as of a system. , normal cardiac, pulmonary, abdominal, and rectal examination. Palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis. of L3-L5 revealed tenderness, and neurologic examination was normal, including straight leg raise The Straight leg raise also, called Lasègue sign or Lasègue test, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk. . ESR ESR - Eric S. Raymond was 91 mm/h (normal <20 mm/h), CRP C-reactive protein (CRP) A protein present in blood serum in various abnormal states, like inflammation. Mentioned in: Pelvic Inflammatory Disease CRP, n.pr See C-reactive protein. >15 mg/dL (normal <1.0 mg/dL) and WBC WBC white blood cell; see leukocyte. WBC abbr. white blood cell WBC, n stands for white blood cell. count was 8.4 k/mm3 (normal 4-8 k/mm3). Lumbar spine x-ray showed irregularity A defect, failure, or mistake in a legal proceeding or lawsuit; a departure from a prescribed rule or regulation. An irregularity is not an unlawful act, however, in certain instances, it is sufficiently serious to render a lawsuit invalid. of the L1/L2 intervertebral intervertebral /in·ter·ver·te·bral/ (-ver´te-bral) situated between two contiguous vertebrae; see under disk. in·ter·ver·te·bral adj. Located between vertebrae. disk, with anterior inferior endplate destruction (Fig. 1). Lumbar spine MRI showed a diffuse marrow replacement process, an abnormal L2-3 disc, and epidural enhancement posterior to L3/L5 vertebral bodies with extension into the paraspinal musculature musculature /mus·cu·la·ture/ (mus´kul-ah-cher) the muscular apparatus of the body or of a part. mus·cu·la·ture n. The arrangement of the muscles in a part or in the body as a whole. (Fig. 2). Computed tomography (CT) of the abdomen and pelvis was negative for pelvic abscess or diverticular disease. Culture of the paraspinous fluid obtained by CT scan-guided core biopsy grew B fragilis sensitive to metronidazole. Blood cultures were negative. A six-week course of oral metronidazole was initiated. The patient's back pain improved, and his CRP was 1.96 mg/dL after two weeks of treatment. At six weeks, his symptoms were completely resolved. Materials and Methods Two investigators independently searched the published English, Spanish and French languages literature through September 2005 using MEDLINE (1966-2005). Search terms included Bacteroides fragilis, anaerobic bacteria, combined with osteomyelitis, vertebral osteomyelitis, discitis, or spondylodiscitis. The bibliographies of selected articles were searched in an effort to identify any other cases. The study selection criteria included all reported cases of vertebral osteomyelitis or spondylodiscitis caused by B fragilis, not related to sacral decubitus ulcers, in adults (age 16 yr and above). Only cases with radiographic radiographic (rā´dēōgraf´ik), adj relating to the process of radiography, the finished product, or its use. , clinical, or laboratory evidence of infection are included in this review. The two authors independently screened title and abstracts before manuscript retrieval. All retrieved articles were read by both authors, and both had agreement on which published articles met the inclusion criteria. The following information was extracted from each eligible article: 1) age and sex of the patients, 2) vertebral level of osteomyelitis, 3) blood culture or tissue culture results, 4) comorbid conditions or risk factors for infection, 5) inflammatory markers, and 6) duration and type of antibiotics used. [FIGURE 1 OMITTED] A third author independently reviewed all articles and extracted data for accuracy. The final pool of eligible publications included 11 articles, publication dates ranging from 1978 to 2005. Eight were written in English, two in Spanish, and one in French. [FIGURE 2 OMITTED] Results of Literature Review The search strategy yielded 15 reported cases. Four of them did not meet the inclusion criteria due to being associated with decubitus ulcer or involvement of other bones such as the clavicle clavicle /clav·i·cle/ (klav´i-k'l) collar bone; a bone, curved like the letter f, that articulates with the sternum and scapula, forming the anterior portion of the shoulder girdle on either side. . The characteristics of the 12 cases, including ours, are shown in the Table. The age of the patients in this series ranged from 17 to 74 years, with a mean age of 55 years. Male to female ratio was 6:1. Lumbar involvement was reported in nine cases, thoracic involvement in two patients and sacral involvement in one patient. B fragilis was recovered by blood culture in four patients and by tissue culture in eight patients. Out of the twelve patients, eight grew pure B fragilis as an isolate, and four patients had B fragilis isolated with other bacteria. Metronidazole was the most common antibiotic used for treatment (eight patients), either as monotherapy or in combination with other antibiotics. Five patients required surgical intervention in the form of bone debridement Debridement Definition Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and other wounds. Purpose Debridement speeds the healing of pressure ulcers, burns, and other wounds. with bone graft or abscess drainage. Discussion Vertebral osteomyelitis (VO) was recognized as a distinct clinical entity by Hippocrates and Galen. (7) The most common microorganisms encountered in VO are Staphylococcus aureus and coagulase-negative staphylococci. (8) Aerobic Gram negative bacteria and candida species are seen commonly in IV drug abusers, immunosuppressed Immunosuppressed A state in which the immune system is suppressed by medications during the treatment of other disorders, like cancer, or following an organ transplantation. Mentioned in: Fifth Disease patients, and postoperative patients. (8) Mycobacterium tuberculosis and Brucella Brucella /Bru·cel·la/ (broo-sel´ah) a genus of schizomycetes (family Brucellaceae). B. abor´tus causes infectious abortion in cattle and is the most common cause of brucellosis in humans. B. spondylodiscitis are common in endemic areas. (8) Anaerobic infection of the bony spine and disc spaces is uncommon and appears to account for less than 3% of all spine infections. (1-3,9) Actinomyces israelii was the first anaerobe anaerobe /an·aer·obe/ (an´ah-rob) an organism that lives and grows in the absence of molecular oxygen. facultative anaerobes to be implicated im·pli·cate tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates 1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot. 2. as a cause of VO and is the most frequently cited cause of anaerobic infection of the spine. (6) Non-Actinomyces VO, other than that caused by direct extension from sacral decubitus ulcers, accounts for only 2% of all reported cases of anaerobic anaerobic /an·aer·o·bic/ (an?ah-ro´bik) 1. lacking molecular oxygen. 2. growing, living, or occurring in the absence of molecular oxygen; pertaining to an anaerobe. osteomyelitis. (10) In a review of 33 cases of anaerobic spondylodiscitis (not including Actinomyces Actinomyces /Ac·ti·no·my·ces/ (-mi´sez) a genus of bacteria (family Actinomycetaceae). Actinomyces israe´lii ) done by Saeed et al, the most common pathogenic organisms isolated included Bacteroides species, Propionibacterium acnes, and Peptococcus species. (6) B fragilis is an anaerobic nonspore forming Gram negative rods and is a major part of colonic and vaginal flora. It is one of the most common anaerobic isolates, (5) but it accounts for only 8% of the isolates in bone infections. (11) It is found especially in infections of the extremities associated with vascular disease or neuropathy. (12) Anaerobic spondylodiscitis commonly results from contiguous extension from an adjacent soft tissue, intra-abdominal, or pelvic focus of infection, or from hematogenous hematogenous /he·ma·tog·e·nous/ (he?mah-toj´e-nus) 1. produced by or derived from the blood. 2. disseminated through the blood stream. he·ma·tog·e·nous adj. 1. seeding from a distant primary site of infection. (6) The reported incidence of B fragilis osteomyelitis after bacteremia is low. (13) In a series that reviewed 1270 episodes of anaerobic bacteremia, only seven patients (0.5%) developed osteomyelitis. (10) Similarly, in our current case series, B fragilis spondylodiscitis resulted from local spread of an adjacent infectious process in 33%. Adjacent infections included parasigmoid abscess, pelvic abscess in a patient with Crohn disease, and a gunshot wound causing presumed intestinal perforation. (1,14,15) Hematogenous spread with unknown or presumed ectopic ectopic /ec·top·ic/ (ek-top´ik) 1. pertaining to ectopia. 2. located away from normal position. 3. arising from an abnormal site or tissue. ec·top·ic adj. source was found in approximately 40%, and probable sources of bacteremia included anal dilation dilation /di·la·tion/ (di-la´shun) 1. the act of dilating or stretching. 2. dilatation. di·la·tion n. 1. , flexible sigmoidoscopy, and perianal abscess (our case and References 13 and 16 through 19). (13,16-19) In three cases (25%), there was no identified source of infection. (20-22) Potential predisposing factors for anaerobic vertebral osteomyelitis have been reported in the literature, and include diabetes mellitus, Gaucher disease, sickle cell anemia sickle cell anemia n. A chronic, usually fatal inherited form of anemia marked by crescent-shaped red blood cells, occurring almost exclusively in Blacks, and characterized by fever, leg ulcers, jaundice, and episodic pain in the joints. , and rheumatoid arthritis. (2,10,11,18,23-26) Diabetes was the only known predisposing factor found in our case review and was identified in only two patients. Presentation of spondylodiscitis varies and can be subtle, although back pain is usually present. In one case series of spondylodiscitis, 92% of patients had back pain at presentation. Less than half of patients will have fever, positive blood cultures, or neurologic deficits. (17) Inflammatory markers including WBC, ESR, CRP are only moderately sensitive, elevated in 27 to 88% of patients with VO. (27,28) A similar pattern is revealed in our case series. Low back pain was the presenting symptom in all patients but one, who only complained of bilateral lower extremity weakness. Six out of eleven patients had leukocytosis Leukocytosis Definition Leukocytosis is a condition characterized by an elevated number of white cells in the blood. Description Leukocytosis is a condition that affects all types of white blood cells. , and ESR/CRP was elevated in all of the nine patients with known results. A needle biopsy is the gold standard for diagnosing VO, but some authors suggest that it is not always required if the clinical and radiographic findings are typical of vertebral osteomyelitis, and blood cultures are positive with a likely pathogen such as S aureus The aureus (pl. aurei) was a gold coin of ancient Rome valued at 25 silver denarii. The aureus was regularly issued from the 1st century BC to the beginning of the 4th century AD, when it was replaced by the solidus. , a Gram negative enteric enteric /en·ter·ic/ (en-ter´ik) within or pertaining to the small intestine. en·ter·ic adj. 1. Of, relating to, or within the intestine. 2. rod, or P aeruginosa. (7) One concern with this approach is that the organisms isolated from blood cultures do not always correlate with culture results from a needle biopsy. (29) Lack of response to treatment chosen on the results of a positive blood culture indicates the need for tissue culture. (22) In injection drug users (IDUs) with vertebral osteomyelitis it is advised to perform invasive diagnostic procedures, even when blood cultures are positive with one organism, as the vertebral infection may be polymicrobial (8, P.D. Brown, personal communication). In our case series, all patients had been diagnosed with B fragilis spondylodiscitis based on a positive blood culture (four patients) or a positive tissue culture (eight patients), but none had both cultures positive for B fragilis. In one patient, the initial therapy for VO was chosen based on his history of Proteus mirabilis bacteremia. This initial regimen failed, with subsequent development of vertebral compression at the 10th thoracic disc space. Culture from a fine needle aspiration fine needle aspiration Diagnostics A method of in which a thin or “skinny”–18- to 23-gauge needle is used to suck in cells or tissue bits for diagnoses; the sites selected for FNAs are often guided by radiologists with fluoroscopy, CT, MRI of the disc space grew B fragilis. The antibiotic regimen was broadened to cover both microorganisms, and there was no further progression of his vertebral compression. (22) Of note, two cases of B fragilis spondylodiscitis were associated with mycotic aneurysms of the common iliac artery Noun 1. common iliac artery - terminal branches of the abdominal aorta arteria iliaca, iliac artery - one of the large arteries supplying blood to the pelvis and legs . Therefore, it is important to consider the possibility of a contained rupture of a mycotic mycotic /my·cot·ic/ (mi-kot´ik) 1. pertaining to mycosis. 2. caused by a fungus. my·cot·ic adj. 1. Relating to mycosis. 2. abdominal aneurysm aneurysm (ăn`y  rĭzəm), localized dilatation of a blood vessel, particularly an artery, or the heart. in all patients with vertebral osteomyelitis
who have acute episodes of severe back pain that differ in character
from the patient's usual pain. (21)
Metronidazole is one of the most predictably active antibiotics against anaerobic Gram negative bacilli bacilli /ba·cil·li/ (bah-sil´i) plural of bacillus. bacilli see bacillus. , including B fragilis. (8) More than 95% of B fragilis are susceptible to metronidazole. B. fragilis has shown increasing resistance in recent years to clindamycin, and in recent surveys, 30% or more of B fragilis isolates were clindamycin resistant. (8,30,31) In our current case series review, metronidazole was used alone or with other antibiotics in nine patients. Other antibiotics used were clindamycin and ampicillin-sulbactam. Therapy failure had not been documented in any of the twelve patients. Conclusion B fragilis is a rare causative agent of spondylodiscitis, but it should be considered in patients with spondylodiscitis who have contiguous intraabdominal or pelvic infections, or who had recent gastrointestinal procedures that may have led to B fragilis bacteremia. Treatment with metronidazole is effective in most of the cases. References 1. Sapico FL, Montgomerie JZ. Pyogenic pyogenic /pyo·gen·ic/ (-jen´ik) suppurative. py·o·gen·ic adj. 1. Producing pus. 2. Of, relating to, or characterized by pyogenesis. vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis 1979;1:754-776. 2. Sapico FL, Montgomerie JZ. Vertebral osteomyelitis. Infect Dis Clin North Am 1990;4:539-550. 3. Perronne C, Saba J, Behloul Z, et al. Pyogenic and tuberculous tuberculous /tu·ber·cu·lous/ (too-ber´ku-lus) pertaining to or affected with tuberculosis; caused by Mycobacterium tuberculosis. tu·ber·cu·lous adj. 1. spondylo-diskitis (vertebral osteomyelitis) in 80 adult patients 1994;19:746-750. 4. Honan Honan: see Henan, China. M, White GW, Eisenberg GM. Spontaneous infectious discitis in adults. Am J Med 1996;100:85-89. 5. Beigelman PM, Rantz LA. Clinical significance of Bacteroides. Arch Intern Med 1949;84:605-611. 6. Saeed MU, Mariani P, Martin C, et al. Anaerobic spondylodiscitis: case series and systematic review. South Med J 2005;98:144-148. 7. Sexton DJ McDonald M. Vertebral Osteomyelitis. www.uptodate.com, version 13.2. Accessed March 2, 2007. 8. Levine DP, Brown PD. Infections in injection drug users. In: Mandell, GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 6th edition. Vol 2. Philadelphia, Elsevier Inc, 2005, pp 3462-3465. 9. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 2002;34:1342-1350. 10. Raff MJ, Melo JC. Anaerobic osteomyelitis. Medicine (Baltimore) 1978;57:83-103. 11. Lewis RP, Sutter VL, Finegold SM. Bone infections involving anaerobic bacteria. Medicine (Baltimore) 1978;57:279-305. 12. Brook I, Frazier EH. Anaerobic osteomyelitis and arthritis in a military hospital: a 10-year experience. Am J Med 1993;94:21-28. 13. Chazan cha·zan or haz·zan also chaz·zan n. A cantor in a synagogue. [Mishnaic Hebrew and Jewish Aramaic B, Strahilevitz J, Millgram MA, et al. Bacteroides fragilis vertebral osteomyelitis secondary to anal dilatation dilatation /dil·a·ta·tion/ (dil?ah-ta´shun) 1. the condition, as of an orifice or tubular structure, of being dilated or stretched beyond normal dimensions. 2. the act of dilating or stretching. . Spine 2001;26:E377-E378. 14. Beaumont S, Winer A, Demeure D, et al. [Parasigmoid abscess revealed by anaerobic osteomyelitis] (in French). Ann Fr Anesth Reanim 2000;19:474-477. 15. Merine D, Fishman EK, Magid D. CT detection of sacral osteomyelitis associated with pelvic abscesses. J Comput Assist Tomogr 1988;12:118-121. 16. Toral Revuelta JR, Llobell Segui G, Peralba Vano JI, Martinez Ruiz M. [Psoas abscess associated to vertebral osteomyelitis and Bacteroides fragilis bacteremia following lower digestive tract endoscopy endoscopy Examination of the body's interior through an instrument inserted into a natural opening or an incision, usually as an outpatient procedure. Endoscopes include the upper gastrointestinal endoscope (for the esophagus, stomach, and duodenum), the colonoscope (for the ] (in Spanish). Med Clin (Barc). 1994;102:597-598. 17. Bilgrami S, Pesanti EL, Singh NT, et al. Spinal cord compression Spinal cord compression develops when the spinal cord is compressed by bone fragments from a vertebral fracture, a tumor, abscess, ruptured intervertebral disc or other lesion. due to anaerobic vertebral osteomyelitis in a patient with metastatic Metastatic The term used to describe a secondary cancer, or one that has spread from one area of the body to another. Mentioned in: Coagulation Disorders metastatic pertaining to or of the nature of a metastasis. prostate cancer. Clin Infect Dis 1995;21:457-458. 18. Boutoille D, Talarmin JP, Prendki V, Raffi F. Hematogenous anaerobic vertebral osteomyelitis due to Bacteroides fragilis in a diabetic patient. Eur J Intern Med 2003;14:63-64. 19. Santin M, Carratala J, Ariza X. [Hematogenous spondylitis spondylitis /spon·dy·li·tis/ (spon?di-li´tis) inflammation of vertebrae. spondylitis ankylopoie´tica , ankylosing spondylitis caused by Bacteroides fragilis] (in Spanish). Enferm Infecc Microbiol Clin 1992;10:380-381. 20. Tsuji Y, Okita Y, Niwaya K, et al. Allograft allograft: see transplantation, medical. replacement of common iliac artery mycotic aneurysm caused by Bacteroides fragilis vertebral spondylitis: a case report. Vasc Endovascular Surg 2003;37:441-444. 21. Doita M, Marui T, Kurosaka M, et al. Contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis. Spine 2001;26:E303-E307. 22. Feng J, Austin TW. Anaerobic vertebral osteomyelitis. CMAJ CMAJ Canadian Medical Association Journal 1991;145:132-133. 23. Finegold SM. Host factors predisposing to anaerobic infections. FEMS Immunol Med Microbiol 1993;6:159-163. 24. Finkelstein R, Nachum Z, Reissman P, et al. Anaerobic osteomyelitis in patients with Gaucher's disease. Clin Infect Dis 1992;15:771-773. 25. Dodd MJ, Griffiths ID, Freeman R. Pyogenic arthritis due to Bacteroides complicating rheumatoid arthritis. Ann Rheum rheum (rldbomacm) any watery or catarrhal discharge. rheum n. A watery or thin mucous discharge from the eyes or nose. rheum any watery or catarrhal discharge. Dis 1982;41:248-249. 26. Ryeen AC, Schean A, Agell BO. A case of septic arthritis in multiple joints due to Bacteroides fragilis in a patient with rheumatoid arthritis. Acta Orthop Scand 1978;49:98-101. 27. Calvo JM, Ramos JL, Garcia F, et al. Pyogenic and non-pyogenic vertebral osteomyelitis: descriptive and comparative study of a series of 40 cases. Enferm Infecc Microbiol Clin 2000;18:452-456. 28. Beronius M, Bergman B, Andersson R. Vertebral osteomyelitis in Goteborg, Sweden: a retrospective study of patients during 1990-95. Scand J Infect Dis 2001;33:527-532. 29. Patzakis MJ, Rao S, Wilkins J, et al. Analysis of 61 cases of vertebral osteomyelitis. Clin Orthop Relat Res 1991;264:178-183. 30. Aldridge KE, Ashcraft D, Cambre K, et al. Multicenter survey of the changing in vitro antimicrobial susceptibilities of clinical isolates of Bacteroides fragilis group, Prevotella, Fusobacterium, Porphyromonas, and Peptostreptococcus species. Antimicrob Agents Chemother 2001;45:1238-1243. 31. Teng LJ, Hsueh PR, Tsai JC, et al. High incidence of cefoxitin and clindamycin resistance among anaerobes in Taiwan. Antimicrob Agents Chemother 2002;46:2908-2913. Hesham Elgouhari, MD, Mohamed Othman, MD, and Wendy H. Gerstein, MD From the University of New Mexico The University of New Mexico (UNM) is a public university in Albuquerque, New Mexico. It was founded in 1889. It also offers multiple bachelor's, master's, doctoral, and professional degree programs in all areas of the arts, sciences, and engineering. and New Mexico Veteran's Administration Health Care System, University of New Mexico, Albuquerque, New Mexico “Albuquerque” redirects here. For other uses, see Albuquerque (disambiguation). Albuquerque (pronounced [ˈæl.bə.kɚ.kiː], Spanish: [al.βu. . Reprint requests to Dr. Wendy H. Gerstein, Division of Infectious Diseases, Department of Medicine, New Mexico Veteran's Health Care System, 1501 San Pedro Drive, SE, Albuquerque, NM 87108-5154. E-mail: wgerstein@salud.unm.edu Accepted January 3, 2007. RELATED ARTICLE: Key Points * Bacteroides fragilis is a rare causative agent of spondylodiscitis. It should be considered in patients with spondylodiscitis who have contiguous intraabdominal or pelvic infections, or who had recent gastrointestinal procedures. * Presentation of spondylodiscitis commonly includes back pain. Less than half of the patients will have fever or neurological deficits. * A needle biopsy is the gold standard for the diagnosis. * More than 95% of Bacteroides fragilis are susceptible to metronidazole. * In recent years, B fragilis has shown increasing resistance to clindamycin.
Table. Characteristics of reported cases of Bacteroides fragilis
vertebral osteomyelitis
Elevated
Age/ Vertebral ESR and/ Elevated
Article title and reference number Sex Level or CRP? WBC
Allograft replacement of common 74/ L4-L5 Yes Yes
iliac artery mycotic aneurysm M
caused by Bacteroides
fragilis vertebral spondylitis-a
case report (20).
Hematogenous anaerobic vertebral 70/ L3-L5 Yes Yes
osteomyelitis due to Bacteroides M
fragilis in a diabetic
patient (18).
Bacteroides fragilis vertebral 17/ L4-L5 Yes No
osteomyelitis secondary to anal M
dilatation (13).
Contained rupture of the aneurysm 60/ L4-L5 Yes Yes
of common iliac artery M
associated with pyogenic
vertebral spondylitis (21).
Parasigmoid abscess revealed by 66/ T4-T7 NS Yes
anaerobic osteomyelitis (14). F
Spinal cord compression due to 65/ L1 NS No
anaerobic vertebral M
osteomyelitis in a patient with
metastatic prostate cancer (17)
Psoas abscess associated with 65/ L4-L5 Yes Yes
vertebral osteomyelitis and F
Bacteroides fragilis bacteremia
following lower digestive tract
endoscopy (16)
Hematogenous spondylitis by 66/ L5-S1 Yes Yes
Bacteroides fragilis (19). M
Anaerobic vertebral 68/ T10-11 Yes No
osteomyelitis (22) M
CT detection of sacral 35/ Sacrum NS Yes
osteomyelitis associated with M
pelvic abscesses (15)
Pyogenic vertebral 18/ L4-L5 Yes No
osteomyelitis: report of nine M
cases and review of the
literature (1)
Current Case 58/ L3-L5 Yes No
M
NS, Not stated; ESR, erythrocyte sedimentation rate; CRP, C-reactive
protein; WBC, white blood count; DM, diabetes mellitus; GPC, Gram
positive cocci; M, male; F, female.
Table. Continued
Presumed
Blood associated
Tissue culture culture condition
B fragilis NS* Mycotic aneurysm
of the common
iliac artery.
NS B fragilis Diabetes mellitus
(DM).
B fragilis NS Repeated anal
dilatation.
B fragilis NS Contained rupture of
aneurysm of
common iliac
artery.
B fragilis and GPC Negative Parasigmoid
abscess.
NS B fragilis Metastatic
carcinoma of the
prostate.
NS B fragilis Flexible
sigmoidoscopy.
NS B fragilis Appendicitis and
appendicular
mucocele.
B fragilis P mirabilis Cholelithiasis
B fragilis and E. Negative Crohn disease
coli
B fragilis, Beta- NS Gunshot wound,
hemolytic bullet fragments
streptococcus, P. over L4.
magnus,
Propionibacterium
and S. epidermidis.
B fragilis Negative Perianal abscess and
DM
Tissue culture Antibiotics Surgical Intervention
B fragilis Ampicillin-sulbactam for Cryopreserved
1 week and oral allograft
tosufloxacin for 4 replacement of
weeks. common iliac artery.
Iliac bone strut
graft to fill the
debrided vertebral
cavity.
NS Metronidazole and No surgical
clindamycin for 6 intervention done
weeks followed by
clindamycin alone for 4
weeks.
B fragilis 8 weeks of oral No surgical
metronidazole. intervention
B fragilis NS Cryopreserved
allograft
replacement of
common iliac artery.
Iliac bone strut
graft to fill the
debrided vertebral
cavity.
B fragilis and GPC Metronidazole and Laminectomy of T4-T7
pristinamycin for 2 for decompression
months. and evacuation of
the abscess.
Sigmoidectomy and
colorectal
anastomosis
NS Metronidazole for 4 Patient declined
weeks. surgical
intervention
NS Metronidazole and -
gentamicin for 4 weeks.
NS Imipenem then oral Appendectomy and
metronidazole for 3 liver biopsy
months.
B fragilis 3 weeks IV cefazolin 1 g No surgical
q.8h. plus intervention
metronidazole 500 mg
q.8.; followed by
amoxicillin-clavulanate
500/125 mg t.i.d. for 3
months.
B fragilis and E. NS Abscess drainage
coli
B fragilis, Beta- Clindamycin and Debridement of L3-L4
hemolytic gentamicin for 6 weeks. with application of
streptococcus, P. cancellous bone
magnus, graft.
Propionibacterium
and S. epidermidis.
B fragilis Metronidazole for 6 No surgical
weeks intervention
Tissue culture Outcome
B fragilis Complete recovery.
(follow up for 3 years)
NS Complete recovery (follow
up for 9 months)
B fragilis Complete recovery
B fragilis Complete recovery
B fragilis and GPC Residual neurological
dysfunction (Persistent
loss of sphincteric
control, and monoplegia
in the left lower limb)
NS Improved on antibiotic but
died 4 months later
from his comorbid
conditions
NS -
NS Complete recovery
B fragilis No further progression of
vertebral compression
B fragilis and E. NS
coli
B fragilis, Beta- Complete recovery (follow
hemolytic up for 6 months)
streptococcus, P.
magnus,
Propionibacterium
and S. epidermidis.
B fragilis Complete recovery
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