J Korean Neurosurg Soc.  2021 Jan;64(1):88-99. 10.3340/jkns.2020.0278.

Clinical Characteristics of Spinal Epidural Abscess Accompanied by Bacteremia

• Chae Hj
• Kim J
• Kim C

• KMID: 2510763
• DOI: http://doi.org/10.3340/jkns.2020.0278

Abstract

Objective
: The treatment of choice for spinal epidural abscess (SEA) generally is urgent surgery in combination with intravenous antibiotic treatment. However, the optimal duration of antibiotic treatment has not been established to date, although 4–8 weeks is generally advised. Moreover, some researchers have reported that bacteremia is a risk factor for failure of antibiotic treatment in SEA. In this study, we investigated the clinical characteristics of SEA accompanied by bacteremia and also determined whether the conventional 4–8 weeks of antibiotic treatment is sufficient.
Methods
: We retrospectively reviewed the medical records and radiological data of 23 patients with bacterial SEA who underwent open surgery from March 2010 to April 2020. All patients had bacteremia preoperatively and underwent weeks of perioperative antibiotic treatments based on their identified organisms until all symptoms of infection disappeared. All patients underwent microbiological studies of peripheral blood, specimens from SEA and concomitant infections. The mean follow-up duration was 35.2 months, excluding three patients who died.
Results
: The male : female ratio was 15 : 8, and the mean age was 68.9 years. The SEA most commonly involved the lumbar spinal segment (73.9%), and the mean size was 2.9 vertebral body lengths. Mean time periods of 8.4 days and 16.6 days were required from admission to diagnosis and from admission to surgery, respectively. Concomitant infections more frequently resulted in delayed diagnosis (p=0.032), masking the symptoms of SEA. Methicillin-sensitive Staphylococcus aureus was the most commonly identified pathogen in both blood and surgical specimens. Seventeen patients (73.9%) showed no deficits at the final follow-up. The overall antibiotic treatment duration was a mean of 66.6 days, excluding three patients who died. This duration was longer than the conventionally advised 4–8 weeks (p=0.010), and psoas or paraspinal abscess required prolonged duration of antibiotic treatment (p=0.038).
Conclusion
: SEA accompanied by bacteremia required a longer duration (>8 weeks) of antibiotic treatment. In addition, the diagnosis was more frequently delayed in patients with concomitant infections. The duration of antibiotic treatment should be extended for SEA with bacteremia, and a high index of suspicion is mandatory for early diagnosis, especially in patients with concomitant infections.

Keyword

Anti-bacterial agents; Bacteremia; Epidural abscess, Spinal; Surgery

Figure

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  Fig. 1. Time interval from admission to radiological diagnosis and operation (days). Each bar graph represents each patient’s time interval from admission to radiological diagnosis and operation. Time to Dx : time interval from admission to radiological diagnosis using magnetic resonance imaging, Time to Op : time interval from radiological diagnosis to operation.

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  Fig. 2. Identified organisms on microbiological study in peripheral blood culture (A), and in surgical specimen culture (B). MRSA : methicillin-resistant Staphylococcus aureus, MSSA : methicillin-sensitive Staphylococcus aureus, MSSE : methicillin-sensitive Staphylococcus epidermidis, S. caprae : Staphylococcus caprae, SAG : Streptococcus anginosus group, S. capitis : Staphylococcus capitis, S. agalactiae : Streptococcus agalactiae-(group B), MRSE : methicillin-resistant Staphylococcus epidermidis, E. faecalis : Enterococcus faecalis, E. coli : Escherichia coli, S. warneri : Staphylococcus warner.

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  Fig. 3. Duration of pre- and postoperative antibiotic treatment (days). Each bar graph represents each patient’s duration of pre- and postoperative antibiotic treatment. *Three patients (#5, #9, and #22) died and consequently their postoperative antibiotic treatments were not fully completed. Preoperative : duration of preoperative antibiotic treatment, Postoperative : duration of postoperative antibiotic treatment.

Reference

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