Treatment of Spinal Hardware Associated Infections

Diagnostic Considerations

Spinal hardware infections present as intense, confluent uptake in soft tissues adjacent to the hardware at multiple contiguous levels on imaging, potentially extending to the bone-hardware interface, according to the European Journal of Nuclear Medicine and Molecular Imaging 1
Differentiation from aseptic inflammation is important, as aseptic loosening typically appears as uptake adjacent to only one or two screws or anchors, as noted by the European Journal of Nuclear Medicine and Molecular Imaging 1
Laboratory markers including ESR and CRP should be monitored to assess treatment response, as recommended by the Infectious Diseases Society of America 2

Surgical consultation should be obtained for all patients with spinal hardware infections, according to the Infectious Diseases Society of America 3
Surgical intervention is indicated for patients with progressive neurological deficits, spinal instability, persistent or recurrent bloodstream infection, worsening pain despite appropriate medical therapy, or significant sequestered paraspinal abscess, as recommended by the Infectious Diseases Society of America 4
Early switch to oral antibiotics with good bioavailability can be considered once CRP has decreased, as suggested by the Infectious Diseases Society of America 4

Parenteral therapy is standard for initial treatment of most gram-positive and gram-negative infections, according to the Infectious Diseases Society of America 5
Oral antibiotics with excellent bioavailability, such as fluoroquinolones, linezolid, and metronidazole, allow early switch to oral route, as recommended by the Infectious Diseases Society of America 5
Antibiotics should be tailored based on culture results and susceptibility testing, as suggested by the Infectious Diseases Society of America 4

Monitor systemic inflammatory markers, such as ESR and CRP, after approximately 4 weeks of therapy, as recommended by the Infectious Diseases Society of America 2
A 25-33% reduction in inflammatory markers after 4 weeks of therapy indicates reduced risk of treatment failure, according to the Infectious Diseases Society of America 2
Routine follow-up MRI is not recommended in patients with favorable clinical and laboratory response, but may be considered in patients with poor clinical response, as suggested by the Infectious Diseases Society of America 2

Unnecessarily prolonged antibiotic courses increase risk of adverse effects, including emergence of resistant pathogens and C. difficile colitis, as warned by the Infectious Diseases Society of America 5
Follow-up imaging performed <4 weeks after baseline may falsely suggest progressive infection despite clinical improvement, according to the Infectious Diseases Society of America 2
Radiographic evidence of ongoing inflammation may persist for months to years without clinical relevance, as noted by the Infectious Diseases Society of America 2