1. Andrea Guyot MD FRCPath MSc DTM&H DipHIC
Educational Workshops 2013
Bone and Joint Infections
Severe back pain after a fall
Andrea Guyot MD FRCPath MSc
DTM&H DipHIC

2. Presentation 78 y old female
Comorbidities: Type II diabetes, infrarenal AAA, on warfarin for FAF, CRF
In November 2010 leg ulcers infected with S. aureus and admission for cellulitis

3. Presentation
fall on back and admission with severe lower back pain and fever (T 38.9 C)
WBC 17, CRP 129

4. Which investigations are useful foR the diagnosis of discitis?

5. X-rays

6. Weeks 1-3
X-ray of lower spine was interpreted as scoliosis with degenerative changes
Blood culture - no growth
Tazocin was given for PUO from
UTI with enterococcus and cellulitis over toe ulcer
MRI for severe lower back pain, CRP 111, WBC 10

7. T1 T2
MRI interpreted as lumbar scoliosis with foraminal narrowing in L5/S1 and L2/L3 with impingement of roots. Incomplete canal stenosis at L2/L3 and T2 signals due to degenerative changes in endplates

8. Weeks 3-5
MRI interpreted as lumbar scoliosis with foraminal narrowing in L5/S1 and L2/L3 with impingement of roots. Incomplete canal stenosis at L2/L3 and T2 signals due to degenerative changes in endplates
Oral flucloxacillin from for cellulitis on foot
Still severe back pain and CRP 93 on 2.12.
Review of MRI concludes now possible discitis L2/L3

9. What is the differential radiological diagnosis of pyogenic discitis?

10. How can pyogenic discitis be confirmed?

11. Disc aspiration on

12. What are the common bacterial aetiological agents of spondylodiscitis?

13. Weeks 6-8 14.12.12 L2 disc aspirate grows S. aureus res: fusidic acid
sens: fluclox, ceftriaxone, teicoplanin, clindamycin, doxycycline, rifampicin

14. Which antibiotic regimen would you choose for this patient, who is not fit for home discharge?

15. Weeks 6-8
Flucloxacillin 2g 6hrly x 6-12 weeks or ceftriaxone 2g od as OPAT
Transfer to community hospital for rehabilitation on flucloxacillin iv via PICC line

16. What are the antibiotic concentrations in bone?

17. What are the CURE RATES?

18. Weeks 9-10
Transfer back to acute hospital on for hypokalaemia, CRP 40
On still back pain and CRP 22

19. how long would you give antbiotics for spondylodiscitis?

20. WHICH MARKERS ARE USEFUL FOR MONITORING CURE?

22. Weeks 11-12
MRI reported as increased fluid in the intervertebral disc space L2/L3 and also in L1/L2, absence of psoas abscess and spinal stenosis. Worsening irregularity of vertebral endplates
Home discharge plan and change to ceftriaxone on
On unfit for discharge and change to iv flucloxacillin
On CRP and WBC rising, fever and hypotension

23. Week 13
On onset of diarrhoea: oral vancomycin started for CDI and iv gentamicin for sepsis
GDH positive and Vidas CD toxin equivocal
septic shock, AKI, unsuitable for ITU
End of life care pathway