Approach to managing vertebral osteomyelitis in adults

Treatment of vertebral osteomyelitis in adults can be difficult. In addition to antimicrobial therapy, surgery may be required; it should be considered for patients with spinal epidural abscesses or paraspinal collections, and is critical for patients with neurological compromise. Seek expert advice.

Note: Urgent empirical antibiotic therapy is required for adults with sepsis or septic shock, or neurological compromise.

For adults with signs and symptoms of sepsis or septic shock, urgent empirical therapy is required. Start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after blood samples are taken for culture. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.

Urgent empirical therapy is also required for adults with spinal epidural abscess or neurological compromise without sepsis or septic shock. For antibiotic regimens, see Vertebral osteomyelitis associated with spinal epidural abscess or neurological compromise in adults. Some patients with vertebral osteomyelitis associated with spinal epidural abscess or neurological compromise will be critically ill or have meningitis. To ensure adequate drug exposure in these patients, modified dosages of flucloxacillin and ceftriaxone are recommended. This is because pharmacokinetics may be altered in critical illness (eg because of enhanced kidney clearance or changes in volume of distribution). Once the critical illness has resolved, consider switching to the standard dosage.

In adults with vertebral osteomyelitis who have a normal neurological examination and do not have sepsis or septic shock, withhold antibiotic therapy until a definitive microbiological diagnosis is made.

Ongoing pain can be expected for months after treatment is completed and does not necessarily indicate that infection is unresolved; it may be a symptom of vertebral instability. Magnetic resonance imaging (MRI) changes lag behind clinical response, so repeat MRI scans are not useful for monitoring infection resolution. They are recommended if there are new or changing neurological signs.