Discitis and osteomyelitis are seen in end-stage renal disease (ESRD) patients due to repeated vascular access for hemodialysis and urinary tract infections leading to recurrent bacteremia. Discitis and osteomyelitis are underdiagnosed due to the nonspecific initial presentation of back pain. In this article, we review the literature for better understanding of the problem and the importance of early diagnosis by primary care physicians and nephrologists. In addition, we discuss the decision-making, follow-up, management, and neurological outcomes.
A detailed PubMed search was performed using the following terms: “end stage renal disease (ESRD)” and “chronic renal failure (CRF),” combined with “spine infections,” “spondylodiscitis,” “discitis,” and “osteomyelitis.” Search results were limited to articles written in English, case reports, and case series from 1973 to 2012. Editorials, reviews, and commentaries were excluded. Only studies involving human patients were included. The authors also included 4 patients from their own patient population.
A total of 30 articles met the inclusion criteria. Including the 4 patients from the authors’ patient population, 212 patients with spine infections and maintenance dialysis were identified. The patients’ ages ranged from 38 to 78 years. The duration of dialysis ranged from a few days to 16 years. The time from onset of back pain to diagnosis ranged from 3 days to 6 months. The most common causative organism was Staphylococcus aureus, followed by Staphylococcus epidermidis and gram-negative bacteria. Most of the patients were treated with antibiotics alone (76.8%), although surgery was indicated when patients presented with neurological deficits (p < 0.011). Approximately one-quarter of the patients developed neurological deficits, with devastating consequences. Fever and neurological deficits at presentation, culture positive for methicillin-resistant S. aureus, and age > 65 years were highly correlated with mortality in our analysis.
Several risk factors lead to failure of antibiotics and progression of disease in patients with ESRD. Challenges to diagnosis include vague presenting symptoms, co-existing destructive spondyloarthropathy, poor immune response, chronic elevations of inflammatory markers, and recurrent bacteremia. Infectious processes are more likely to cause permanent neurological deficits than transient deficits. The authors recommend close observation and serial imaging of these patients for early signs of neurological deficits. Any signs of disease progression will require aggressive surgical debridement.
ABBREVIATIONSCVC = central venous catheter; ESRD = end-stage renal disease; MRSA = methicillin-resistant Staphylococcus aureus; OR = odds ratio; UTI = urinary tract infection.
AhmedAEAlshukairiANAl-JahdaliHAlaqeelMSiddiqSSAlsaabHA: Development of a risk-prediction model for Middle East respiratory syndrome coronavirus infection in dialysis patients. Hemodial Int22:474–4792018
Cebrián ParraJLSaez-Arenillas MartínAUrda Martínez-AedoALSoler IvañezIAgredaELopez-Duran SternL: Management of infectious discitis. Outcome in one hundred and eight patients in a university hospital. Int Orthop36:239–2442012
ChongBSWBreretonCJGordonADavisJS: Epidemiology, microbiological diagnosis, and clinical outcomes in pyogenic vertebral osteomyelitis: a 10-year retrospective cohort study. Open Forum Infect Dis5:ofy0372018
KovalikECRaymondJRAlbersFJBerkobenMButterlyDWMontellaB: A clustering of epidural abscesses in chronic hemodialysis patients: risks of salvaging access catheters in cases of infection. J Am Soc Nephrol7:2264–22671996
LegrandEFlipoRMGuggenbuhlPMassonCMaillefertJFSoubrierM: Management of nontuberculous infectious discitis. Treatments used in 110 patients admitted to 12 teaching hospitals in France. Joint Bone Spine68:504–5092001
LemaignenAGhoutIDinhAGrasGFantinBZarroukV: Characteristics of and risk factors for severe neurological deficit in patients with pyogenic vertebral osteomyelitis: a case-control study. Medicine (Baltimore)96:e63872017
MelzerMGoldsmithDGransdenW: Successful treatment of vertebral osteomyelitis with linezolid in a patient receiving hemodialysis and with persistent methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus bacteremias. Clin Infect Dis31:208–2092000
MermelLAAllonMBouzaECravenDEFlynnPO’GradyNP: Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis49:1–452009
MuffolerroAJNaderRWestmarkRMNautaHJGargesKJHadjipavlouAG: Hematogenous pyogenic facet joint infection of the subaxial cervical spine. A report of two cases and review of the literature. J Neurosurg95 (1 Suppl):135–1382001
National Institute of Diabetes and Digestive and Kidney Diseases: Kidney Disease Statistics for the United States. Bethesda, MD: NIDDK2016(https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease) [Accessed October 21 2018]
National Kidney Foundation: End Stage Renal Disease in the United States. New York: NKF2017(https://www.kidney.org/news/newsroom/factsheets/End-Stage-Renal-Disease-in-the-US) [Accessed October 21 2018]
NowakMOszukowskiPSzpakowskiMWładzińskiJKamińskiTMalinowskiA: [Intrauterine infection. II. The effect of intravenous dexamethasone on the results of C-reactive protein, white blood cell count and erythrocyte sedimentation rate during the expectant management of premature rupture of membranes.] Ginekol Pol69:623–6271998(Polish)
PhilipneriMAl-AlyZAminKGellensMEBastaniB: Routine replacement of tunneled, cuffed, hemodialysis catheters eliminates paraspinal/vertebral infections in patients with catheter-associated bacteremia. Am J Nephrol23:202–2072003
RiedenKRitzEPostKBarthHPHaufeSWannenmacherM: [Dialysis-associated amyloidosis. Part 2: Incidence and site of osseous amyloidosis. Dialysis characteristics and clinical findings.] Bildgebung60:68–751993(Ger)
RosenbergM: Overview of the management of chronic kidney disease in adults. UpToDate. 2018(https://www.uptodate.com/contents/overview-of-the-management-of-chronic-kidney-disease-in-adults) [Accessed October 18 2018]
US Renal Data System: USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases2013