Infectious spondylitis in the Balearic Islands: An analysis of 51 cases

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Raya Cruz, H.H. Vilchez Rueda, C.I. Marinescu, H. Sarasíbar Ezcurra, M. Riera Jaume, A. Payeras Cifre" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Raya Cruz" "email" => array:1 [ 0 => "manuelraya@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "H.H." "apellidos" => "Vilchez Rueda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C.I." "apellidos" => "Marinescu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "H." "apellidos" => "Sarasíbar Ezcurra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Riera Jaume" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Payeras Cifre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna y Enfermedades Infecciosas, Hospital Son Llàtzer, Palma de Mallorca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna y Enfermedades Infecciosas, Hospital Son Espases, Palma de Mallorca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Son Llàtzer, Palma de Mallorca, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Espondilitis infecciosa en Baleares: análisis de 51 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1319 "Ancho" => 2653 "Tamanyo" => 67091 ] ] "descripcion" => array:1 [ "en" => "Annual incidence of cases of spondylodiscitis in Mallorca (2004–2013)." ] ] ] "textoCompleto" => "<elsevierMultimedia ident="tb0005"></elsevierMultimedia>BackgroundInfectious spondylitis (IS), also known as vertebral osteomyelitis or spondylodiscitis, is an uncommon disease (3–5% of cases of osteomyelitis), with a incidence that varies between 2.2 and 9 cases/100,000 inhabitants/year, according to published Spanish series.<a class="elsevierStyleCrossRefs" href="#bib0100">1,2</a> Patients with IE are mostly men between the ages of 50 and 70 years with predisposing factors such as spinal surgery, prior bacteremia and parenteral drug use (PDU).<a class="elsevierStyleCrossRef" href="#bib0110">3</a> The incidence of IS has increased in recent years due to the availability of better diagnostic methods and the increase in nosocomial infections, the rates of spinal surgery and the number of patients with immunosuppression.<a class="elsevierStyleCrossRef" href="#bib0115">4</a> IS is produced by hematogenous dissemination (with a extraspinal focus), by direct external inoculation (spinal or trauma surgery) or by contiguity (from a close infectious focus).<a class="elsevierStyleCrossRef" href="#bib0120">5</a> The clinical condition is fairly nonspecific, often leading to a delay in the diagnosis, which at times requires the implementation of invasive techniques or surgery to determine the causal microorganism.<a class="elsevierStyleCrossRef" href="#bib0125">6</a> The microorganism most often involved is Staphylococcus aureus (S. aureus), followed by Gram-negative bacilli. In our community and in a not too distant past, Mycobacterium tuberculosis (M. tuberculosis) and Brucella melitensis were common.<a class="elsevierStyleCrossRefs" href="#bib0130">7,8</a> IS can cause pain-related conditions and neurological deficits, at times irreversible, and its mortality is approximately 5%.<a class="elsevierStyleCrossRef" href="#bib0110">3</a>The Spanish publications of case series of IS have been few in recent years, during which IS appears to have undergone significant changes in its clinical–epidemiological characteristics. The aim of this study was to describe the epidemiological, clinical and etiological characteristics and outcomes of patients who have presented IS in 2 hospitals of Palma de Mallorca.Patients and methodsA series of retrospective cases conducted in 2 hospitals on the island of Mallorca that cover a population of approximately 550,000 inhabitants. We included all patients over 15 years of age with a diagnosis of IS from January 1, 2003 to October 31, 2013. The data were obtained from the diagnostic coding database of the department of clinical archives and documentation of the 2 hospitals.A diagnosis of IS was established when there was a compatible clinical condition (lumbar pain, fever and muscle pain during the physical examination), supported by an imaging technique: (a) plain radiography with vertebral endplate disintegration, reduced joint space or vertebral body destruction; (b) computed axial tomography (CT scan) with subchondral bone destruction, loss of cortical margin of the vertebral endplate or periosteal reaction; (c) magnetic resonance imaging (MRI) with reduced signal of the vertebra and intervertebral disc on T1, increased signal of the vertebra and disc in T2, loss of definition of the vertebral endplate; and (d) bone scintigraphy with tecnecio-99 (GO 99mTc). In terms of the etiological diagnosis, we assessed any isolates in blood or in a sample of the focus obtained during surgery or percutaneous puncture. A diagnosis of spondylitis tuberculous was considered the presence of symptoms and radiological compatible findings, along with positive direct smears for bacilli or M. tuberculosis isolates in Lowenstein-Jensen medium with no other bacterial isolate. We also considered a positive PCR for M. tuberculosis of any microbiological sample, a positive tuberculin test or QuantiFERON – TB Gold®, along with clinical and radiological improvement after starting tuberculostatic treatment.The following variables were collected:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Demographic: age, sex and date of admission.</li><li class="elsevierStyleListItem" id="lsti0010">2.Predisposing factors: PDU, spinal surgery, previous bacteremia, associated comorbidities according to the Charlson classification and functional state assessed with the Barthel index.</li><li class="elsevierStyleListItem" id="lsti0015">3.Clinical manifestations: days elapsed from symptom onset to diagnosis, presence of lumbar pain, fever, pain during the physical examination or neurological symptoms (radicular pain, paresthesia, paresis or paralysis).</li><li class="elsevierStyleListItem" id="lsti0020">4.Results of additional tests: leukocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), performance of simple radiology, CT scan, MRI or GO 99mTc.</li><li class="elsevierStyleListItem" id="lsti0025">5.Microbiological data: results of blood cultures, samples obtained using percutaneous puncture or surgery at the IS focus, recent bacteremia in the last month and, in the case of M. tuberculosis infection, we also collected the results of the tuberculin test, CRP for M. tuberculosis or the QuantiFERON – TB Gold®.</li><li class="elsevierStyleListItem" id="lsti0030">6.Treatment: We assessed the antibiotic treatment, both empiric and targeted and treatment duration, whether intravenous or oral, and recorded the reasons for any change in antibiotic treatment. We also recorded the need and reasons for surgical treatment (including the diagnostic method, medical treatment failure, abscess drainage and bone marrow pressure).</li><li class="elsevierStyleListItem" id="lsti0035">7.Evolution in the acute phase: presence of chronic cutaneous fistulae and epidural, paravertebral or psoas abscesses.</li><li class="elsevierStyleListItem" id="lsti0040">8.Follow-up during the first year: presence of sequelae in the form of residual chronic pain or neurological deficiency, as well as the evolution to clinical or microbiological healing, in cases where sequelae were detected, mortality or related overall according to the discretion of the researchers provided there was a direct relationship between the infection and death.</li></ul>A basic statistical analysis was conducted using frequency calculation for each qualitative variable and the mean, standard deviation (SD), median and interquartile range (IQR) for the quantitative variables. We then performed a univariate analysis on the qualitative variables using the chi-squared test (Fisher's test for those cases that required it), as well as a risk estimate using the odds ratio calculation with its 95% confidence intervals (95% CI). For the comparison of quantitative variables, we used Student's t-test. The level of statistical significance was established at .05 (in all hypothesis testing, the null hypothesis was rejected with an error type I or an alpha error <0.05). All calculations were performed with the statistical bundle SPSS 12.0 for Windows. The confidentiality of the recorded data was ensured.ResultsA total of 51 cases of IS were recorded; 37 (72.5%) were of men and 14 were of women (27.5%). The median age was 66 years (IQR: 22–85), and 28 patients (54.9%) were older than 65 years. The cumulative incidence was 9 cases/106 inhabitants/year, and the mean annual incidence was 5.1 cases/year, with the distribution shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Twenty-three patients (45.1%) presented bacteremia in the 30 days prior to the bone infection diagnosis. The origin of the bacteremia was urinary in 10 (43.5%) patients, catheter in 5 (21.7%) patients, respiratory in 3 (13%) patients, endocardial in 3 (13%) patients and skin or soft tissue in 2 (8.7%) patients. Six patients (11.8%) were PDU and 6 (11.8%) had undergone prior spinal surgery.The comorbidities present in the patients included in this study are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The median Charlson comorbidity index was 2.8 points (range: 0–13). Four (7.8%) patients had severe dependence (Barthel index <35 points), 9 (17.6%) had mild to moderate dependence (>40 points) and 38 (74.5%) were independent.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The most common presentation was spondylodiscitis in 48 (94.1%) cases, while 2 (3.9%) cases presented spondylitis without discitis, and 1 (1.9%) presented posterior segment infection (vertebral arches and spinous process). The most common location was the lumbar spine in 30 (58.8%) patients, dorsal in 15 (29.4%) and cervical in 6 (11.8%). All patients showed a single focal involvement, except for one patient who had cervical and dorsal involvement.The most common symptom was fever (35 cases; 68.8%), while 14 (27.5%) patients reported radicular pain. During the examination, 32 (62.7%) patients experienced focal pain on palpation in the area of the lesion, and 10 (19.6%) patients experienced paralysis, paresis or paresthesia. The mean elapsed time from symptom onset to diagnosis was 80.1±125.1 days. Leukocytosis was detected (≥11,000 leukocytes/L) in 22 (43.1%) cases, the median CRP was 14 (1–320) mg/dL, and the median ESR was 48 (10–40) mm/h. Thirty-eight (74.5%) plain spine radiographs were performed, 23 (60.5%) of which revealed pathological findings. CT scans were performed on 34 (66.6%) patients, 32 of which revealed pathological findings (94.1%). MRIs were performed on 46 (90.2%) patients, all of them revealing pathological findings (100%). GO 99mTc was performed on 12 (23.5%) patients, with normal results on 2 occasions (16.7%).The IS had a hematogenous origin in 36 (70.6%) patients, was due to contiguity in 4 (7.8%) patients, was postsurgical or post-trauma in 3 (5.9%) patients and was of unknown origin in 8 (15.7%) patients. Forty-four (86.3%) cases were caused by pyogenic bacteria; M. tuberculosis was isolated in 4 (7.8%) cases. In 3 (5.9%) cases, the causal microorganism could not be determined despite performing a percutaneous puncture on the lesion. For the patients without microbiological isolates, the time to diagnosis was 283.3 days (10–420), much longer than the 67.4 (1–450) days required by the patients with a confirmed etiology (p<.05). Statistically significant differences were not found however in terms of treatment time and sequelae.The causal agents involved are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The most common microorganism was S. aureus in 23 (52.3%) patients of whom 2 were methicillin-resistant (MRSA), followed by Pseudomonas aeruginosa in 6 (13.7%) patients, E. coli in 5 (11.4%), Salmonella and other enterobacteriaceae in 2 (4.5%), Enterococcus faecalis in 2 (4.5%), Bacteroides fragilis in 2 (4.5%), Streptococcus spp. in 2 (4.5%) and coagulase-negative staphylococci in 2 (4.5%) patients.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Serologies for Brucella (Rose Bengal and total antibodies) were conducted for 10 (5.1%) patients, all of which were negative. In 6 of the 10 (60%) cases, the tuberculin test yielded positive results. A QuantiFERON-TB Gold® test was performed in 2 (3.9%) cases, which yielded a positive result in only 1 case; the CRP for M. tuberculosis was positive in only 1 case. Microorganisms were isolated in 7 (87.5%) of the 8 patients who underwent surgery, in 11 (50%) of the 22 who underwent percutaneous puncture and in 27 (65.8%) of the 41 for whom blood cultures were performed. Significant differences were detected when comparing the characteristics of patients with pyogenic germs vs. those for whom no germ could be identified. The former group had a shorter time to diagnosis (61.9 vs. 129.33 days; 95% CI 80.9–363.3; p<.05) and shorter treatment (40.6 vs. 87.7 days; 95% CI 14.7–120.1; p=.01). The main differences between the cases of IS included in this study according to whether they had a pyogenic or tuberculous etiology are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Empiric antibiotic treatment was monotherapy for 18 (35.3%) patients, double therapy for 20 (39.2%) and triple therapy for 4 (7.8%) patients. No empiric treatment was administered to 9 (17.6%) patients. The empirically administered antibiotics were cloxacillin in 15 cases (21.1%), vancomycin in 12 (16.9%), aminoglycosides in 9 (12.7%), other penicillins in 9 (12.7%), cephalosporins in 8 (11.3%), rifampicin on 5 (7%), carbapenems in 4 (5.6%), quinolones in 3 (4.2%), linezolid in 2 (2.8%), tuberculostatic agents in 2 (2.8%), daptomycin in 1 (1.4%) and teicoplanin in 1 (1.4%) case. The treatment was changed for 42 (82.3%) patients. For 11 of these patients (26.2%), the treatment was adjusted based on the results of the antibiogram; the reason for changing treatment in the remaining patients was not reported or specified in the comments of the medical history. The antibiotics most frequently used as targeted treatment were quinolones in 17 (24.3%) cases, cloxacillin in 14 (20%), rifampicin in 13 (18.6%), cephalosporins in 7 (10%), other penicillins in 6 (8.6%), aminoglycosides in 4 (5.7%), carbapenems in 3 (4.3%), vancomycin in 3 (4.3%), linezolid in 1 (1.4%), clindamycin in 1 (1.4%) and teicoplanin in 1 (1.4%) case. Of the 6 (11.7%) patients who underwent empirical treatment with tuberculostatic agents, M. tuberculosis was isolated in 4. No IS-causing microorganism could be isolated in the 2 remaining patients, although they progressed favorably with no complications during the follow-up.The mean total treatment time was 78.92 days (SD, 66.4). Antibiotic treatment was administered intravenously for 29.64 days (SD, 16.1) and orally for 71.61 days (SD, 75.3). The cases of IS of tuberculosis origin were treated for 212 days (SD, 75).Twelve patients (23.5%) required some type of surgical management; 5 (41.6%) for abscess draining, 5 (41.6%) for spinal decompression, 1 (8.3%) due to treatment failure and 1 (8.3%) for diagnostic purposes.During the acute phase, 12 patients (23.5%) developed paravertebral abscesses, 8 (15.7%) developed epidural abscesses and 3 (5.9%) developed psoas abscesses. Seven patients (13.7%) presented long-term residual neurological deficits and 6 (11.8%) maintained chronic pain. Thirty-six patients (70.6%) were clinically cured, 4 (7.8%) presented sequelae despite demonstrating microbiological healing, and another 6 (11.8%) died, although only one of them died for reasons directly related to the infection. Due to an inability to maintain clinical follow-up, we were not able to determine the outcome of 5 (9.8%) patients.The patients who presented acute complications or long-term sequela presented comorbidities (median Charlson's index of 4 points [IQR 0–13] vs. 2 points [IQR 0–11]; p=.068), neurological symptoms at symptom onset (14 [58.3%] vs. 3 [11.1%], p<.005) and required surgery (10 [83.3%] vs. 2 [6.2%], p<.005), with a greater frequency than the other patients who did not present acute complications or long-term sequelae.DiscussionThis study describes the main clinical and epidemiological characteristics of 51 cases of IS that required hospitalization and were treated in 2 hospital centers in Mallorca between 2003 and 2013. This study represents the third largest Spanish series, in terms of the number of included patients, published in the last 10 years.<a class="elsevierStyleCrossRefs" href="#bib0100">1,2,6,9,10</a>In our study, the incidence of IS was 9 cases×106 inhabitants/year, the same rate reported more recently by Ruiz Martín et al.<a class="elsevierStyleCrossRef" href="#bib0105">2</a> and similar to the largest series reported in Spain by Colmenero et al., <a class="elsevierStyleCrossRef" href="#bib0130">7</a> who observed an incidence of 7 cases×106 inhabitants/year. These results indicate that despite the increase in the incidence reported by a number of authors,<a class="elsevierStyleCrossRef" href="#bib0150">11</a> the incidence in our community has not changed significantly.The disease antecedents that have classically been related to IS,<a class="elsevierStyleCrossRef" href="#bib0155">12</a> such as diabetes mellitus, liver disease, neoplasms and immunosuppression, are also the most common in our series. Although 54.9% of the patients were older than 65 years, as can be deduced from the estimates of the Charlson and Barthel indices, they did not present a significant degree of comorbidity, and 74.5% of the patients were completely independent.The most common location for IS was lumbar. The clinical condition was characterized by the presence of fever, focal pain in the lesion and, in a significant minority of cases (19.6%), focal neurological impairment in the form of paralysis, paresis, algias or paresthesia. This high percentage could be related to the delay from symptom onset to diagnosis that occurred in our series. The additional tests included detecting the presence of leukocytosis, increased PCR and ESR.The diagnostic sensitivities of the spine imaging tests were 60.5% for the plain radiology, 83.3% for the GO 99mTc, 94.1% for the CT scan and 100% for the MRI, results very similar to those reported previously,<a class="elsevierStyleCrossRefs" href="#bib0105">2,9</a> except for the plain radiography, which could be due to the difficulty in interpreting the often nonspecific radiological changes.The origin of the IS was mostly hematogenous. In our series, only 3 patients had previously undergone surgery, which differs from previous observations.<a class="elsevierStyleCrossRef" href="#bib0160">13</a> In most cases, the IS was caused by pyogenic germs (86.3%), with monobacterial isolates in all cases. The most common microorganism was S. aureus (52.3%), coinciding with the findings of other series.<a class="elsevierStyleCrossRefs" href="#bib0100">1,6,10</a> The presence of MRSA was not a noteworthy aspect of our series (only 2 cases had MRSA), in contrast to that observed in other series that found increases in its incidence, which were hypothetically related to hospital care.<a class="elsevierStyleCrossRef" href="#bib0165">14</a> Although the incidence in 2012 of M. tuberculosis infection in all of its clinical forms in the Balearic Islands was 12.8 cases per 100,000 inhabitants,<a class="elsevierStyleCrossRef" href="#bib0170">15</a> the number of cases of tuberculous IS has been low, given that the latest case was diagnosed in 2008. It is worth noting that in our series there was no case of IS caused by Brucella and that since 2010 the Balearic Islands have been considered by the European Union as a territory unscathed by bovine and caprine brucellosis.<a class="elsevierStyleCrossRef" href="#bib0175">16</a>Our results support the diagnostic yield of percutaneous punctures and, when necessary, surgical approaches, enabling accurate microbiological diagnoses to be reached, which in turn enable the most appropriate treatment to be administered.In our series, 17.6% of the cases started antibiotherapy empirically until the microorganism responsible for the infection was identified. In the majority of cases, empiric antibiotherapy was likely started due to the presence of fever and nonspecific symptoms, a situation that could have been accompanied by reduced diagnostic yields. Although the current trend is to decrease the antibiotic treatment duration,<a class="elsevierStyleCrossRef" href="#bib0145">10</a> there is controversy given that the duration depends fundamentally on the microbiological isolate, the presence of bacteremia, the presence of endocarditis, paravertebral abscesses that require drainage, the patient's general condition, etc. To start empiric antibiotherapy, it is important to characterize the various clinical conditions. In our study, the comparisons performed between the various etiologies show that spondylodiscitis of pyogenic origin has a higher frequency of previous bacteremia and is diagnosed earlier than spondylodiscitis of tuberculosis or unidentified origin. We also have no randomized clinical trials, and the current recommendations range from 6 weeks<a class="elsevierStyleCrossRef" href="#bib0180">17</a> to 3 months,<a class="elsevierStyleCrossRef" href="#bib0185">18</a> with an intravenous treatment duration of at least 4 weeks. In our study, the patients underwent treatment for 78.92 days, of which intravenous administration used 29.64 days. All patients with IS of tuberculosis origin underwent treatment for at least 6 months, according to the recommendations of the treatment guidelines.<a class="elsevierStyleCrossRef" href="#bib0190">19</a>In our series, almost half of the patients presented localized complications during the acute phase. As occurred in other series,<a class="elsevierStyleCrossRefs" href="#bib0100">1,2</a> mortality was low, although morbidity was high given that chronic pain or residual neurological deficits were detected in almost a quarter of the cases during follow-up, which compromised the patients’ quality of life. It is possible that a greater index of suspicion and a shorter delay in the diagnosis of IS could reduce these types of complications.Our study's limitations include its retrospective nature. Selecting cases according to the coding of the discharge report could have led us to underestimate the number of cases, due to errors in the preparation or coding of the report. However, it seems fairly unlikely given the characteristics of IS. The intervention by various specialists from 2 hospital centers, with no homogeneous diagnostic and therapeutic criteria, could have affected our results. The collection of samples using percutaneous puncture was conducted by different physicians in the department of radiology and was guided by ultrasonography or CT. We therefore cannot ensure that the method for collecting samples was the same in all cases. We cannot rule out the fact that during the follow-up (after discharge) a number of patients were treated in other hospital centers, both public and private, although this number is probably low given that the participating hospitals are the centers that treat the largest percentage of the population in Mallorca.We can conclude that the incidence of IS has not changed significantly over the last decade, a fact that can be observed mainly in patients with associated comorbidity (although without a high degree of dependence). The main etiology of IS is S. Aureus, which usually presents a long diagnostic delay and, although it causes low mortality, frequently causes disabling sequelae. The selective performance of percutaneous punctures, accompanied by blood cultures, improves the diagnostic performance.Conflict of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres519458" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec539981" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres519457" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec539982" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-10" "fechaAceptado" => "2015-01-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec539981" "palabras" => array:6 [ 0 => "Bone diseases" 1 => "Infectious" 2 => "Spondylitis" 3 => "Discitis" 4 => "Spinal tuberculosis" 5 => "Osteoarticular tuberculosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec539982" "palabras" => array:6 [ 0 => "Enfermedades óseas" 1 => "Infecciosas" 2 => "Espondilitis" 3 => "Discitis" 4 => "Tuberculosis espinal" 5 => "Tuberculosis osteoarticular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionVertebral osteomyelitis (VO) is a rare entity, although its incidence has increased in recent years. The objective is to describe the patients with this infection in our environment and a comparison with other published series. MethodsA retrospective review was conducted of epidemiological, clinical, microbiological, treatment, complications and evolution data of patients with VO during 10 years (2004–2014) in two hospitals of Mallorca. Results51 cases, median age 66 (range 22–85) years, 37 (72.5%) men with a mean onset of symptoms of 80.1±125.1 days. In thirty-six (70.6%) cases the origin of infection was considered hematogenous, although previous bacteremia was documented in 23 (45%) cases, being of urinary in 10 (43.5%) cases. Clinically at the moment of diagnosis 35 (68.8%) had fever, 32 (62.7%) pain, 14 (27.5%) irradiated nerve pain and 10 (19.6%) paralysis/paresia. MRI was the most performed radiological test 46 (90.2%), being pathological in all cases. Staphylococcus aureus 23 (52.3%) was the most common microbiological isolates. At the moment of the diagnosis, blood cultures were positive in 27 (65.8%) of 41 cases and 11 (50%) of 22 percutaneous puncture was positive. Paraspinal, epidural or psoas abscesses were observed in 23 (45.1%), neurological deficit in 7 (13.7%) and chronic pain in 6 (11.8%). One patient (1.9%) died in relation with infection. ConclusionsDiagnosis was delayed in most cases. Previous bacteremia being main predisposing factor and hematogenous origin the main source of infection. S. aureus was the most isolated. Percutaneous puncture together with blood cultures increase etiologic diagnosis. A high percentage of patients had complications or sequelae." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa espondilitis infecciosa (EI) es una entidad poco frecuente cuya incidencia ha aumentado en los últimos años. El objetivo de este estudio ha sido describir los casos con EI y realizar una comparación con el resto de series publicadas. Material y métodosEstudio retrospectivo donde se describen datos epidemiológicos, microbiológicos y clínicos de los pacientes diagnosticados de EI durante un periodo de 10 años (2004-2014) en 2 hospitales de Mallorca. ResultadosSe incluyó un total de 51 pacientes, con una edad mediana de 66 años (rango 22-85). El 72,5% (37/51) fueron varones. El tiempo medio transcurrido desde el inicio de la clínica hasta el diagnóstico fue de 80,1±125,1 días. En 36 ocasiones (70,6%) el origen fue hematógeno. El factor predisponente más frecuente fue presentar bacteriemia previa (10 [43,5%] de origen urinario). Presentaron fiebre 35 pacientes (68,8%), dolor 32 (62,7%), radiculalgia 14 (27,5%) y parálisis/paresia 10 (19,6%). La prueba diagnóstica más utilizada fue la resonancia magnética (46 [90,2%]), resultando patológica en todos los casos. El microorganismo etiológico más frecuente fue Staphylococcus aureus (23 [52,3%]). Los hemocultivos resultaron positivos en 27/41 ocasiones (65,8%) y la punción percutánea en 11/22 (50%). Veintitrés pacientes (45,1%) desarrollaron abscesos paravertebrales, epidurales o del psoas, 7 (13,7%) déficits neurológicos residuales y 6 (11,8%) dolor crónico. Un paciente (1,9%) falleció por motivos relacionados con la infección. ConclusionesLa EI es poco frecuente. Su origen usualmente es hematógeno. La bacteriemia previa es el factor predisponente más importante. El diagnóstico es habitualmente tardío, siendo Staphylococcus aureus el germen implicado con mayor frecuencia. La realización de punciones percutáneas acompañando a los hemocultivos aumenta la rentabilidad diagnóstica." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Raya Cruz M, Vilchez Rueda HH, Marinescu CI, Sarasíbar Ezcurra H, Riera Jaume M, Payeras Cifre A. Espondilitis infecciosa en Baleares: análisis de 51 casos. Rev Clin Esp. 2015;215:251–257." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1319 "Ancho" => 2653 "Tamanyo" => 67091 ] ] "descripcion" => array:1 [ "en" => "Annual incidence of cases of spondylodiscitis in Mallorca (2004–2013)." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antecedent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frequency (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sex (male/female) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (72.5)/14 (27.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (23.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Neoplastic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (15.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chronic liver disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (13.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chronic respiratory disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (11.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chronic heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (9.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Peripheral arterial disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (9.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chronic kidney disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (9.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ischemic heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chronic cerebrovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hemiplegia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gastroduodenal ulcer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Acquired immune deficiency syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hematologic neoplastic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Connective tissue disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab838203.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comorbidities present in the 51 cases of spondylodiscitis included in the study." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microbiological isolate \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blood cultures, n (%)N=41 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percutaneous sample, n (%)N=22 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical sample, n (%)N=9 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Staphylococcus aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (36.6)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (27.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (55.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Escherichia coli \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (7.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pseudomonas aeruginosa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.9)<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Coagulase-negative staphylococci \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Streptococcus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Salmonella and other Enterobacteriaceae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Enterococcus faecalis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.4)<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bacteroides fragilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (9.1)<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (34.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab838202.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "In 3 cases, the organism was isolated in blood cultures and in the surgical sample." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "In 3 cases Pseudomonas aeruginosa was isolated in blood cultures by bacteremia prior to the current episode." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "In 1 case, Enterococcus faecalis was isolated in blood cultures by bacteremia prior to the current episode." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "In 1 case, the organism was isolated in the surgical sample and in the percutaneous puncture" ] ] ] "descripcion" => array:1 [ "en" => "Isolated pyogenic microorganisms in the 51 cases of spondylodiscitis included in the study." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pyogenic, n (%)N=44 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tuberculous, n (%)N=4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-Value and 95% confidence interval \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 (11.44–43.64) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diagnosis time ≥60 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (27.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.007 (1.01–1.85) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Previous bacteremia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (52.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.045 (0.71–0.99) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Days of treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">228 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 (118.1–214.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (40.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.038 (1.04–1.48) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab838204.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differences between the cases of pyogenic and tuberculous etiology in the 51 cases of spondylodiscitis included in the study." ] ] 4 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "What we know?Infectious spondylitis is a low-incidence disease. Few series with multiple cases have been published in recent years, and it is possible that significant changes are occurring in its clinical–epidemiological characteristics.What this article provides?The incidence of infectious spondylitis in our community remains stable. The main etiological agent of this disease is Staphylococcus aureus. The involvement of Mycobacterium tuberculosis is very low and that of Brucella melitensis has disappeared completely. 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Original article

Infectious spondylitis in the Balearic Islands: An analysis of 51 cases

Espondilitis infecciosa en Baleares: análisis de 51 casos

M. Raya Cruza,

Corresponding author

manuelraya@hotmail.com

Corresponding author.

, H.H. Vilchez Ruedab, C.I. Marinescub, H. Sarasíbar Ezcurrac, M. Riera Jaumeb, A. Payeras Cifrea

a Servicio de Medicina Interna y Enfermedades Infecciosas, Hospital Son Llàtzer, Palma de Mallorca, Spain

b Servicio de Medicina Interna y Enfermedades Infecciosas, Hospital Son Espases, Palma de Mallorca, Spain

c Servicio de Radiodiagnóstico, Hospital Son Llàtzer, Palma de Mallorca, Spain

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the rates of spinal surgery and the number of patients with immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> IS is produced by hematogenous dissemination &#40;with a extraspinal focus&#41;&#44; by direct external inoculation &#40;spinal or trauma surgery&#41; or by contiguity &#40;from a close infectious focus&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> The clinical condition is fairly nonspecific&#44; often leading to a delay in the diagnosis&#44; which at times requires the implementation of invasive techniques or surgery to determine the causal microorganism&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> The microorganism most often involved is <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;<span class="elsevierStyleItalic">S&#46; aureus</span>&#41;&#44; followed by Gram-negative bacilli&#46; In our community and in a not too distant past&#44; <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> &#40;<span class="elsevierStyleItalic">M&#46; tuberculosis</span>&#41; and <span class="elsevierStyleItalic">Brucella melitensis</span> were common&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7&#44;8</span></a> IS can cause pain-related conditions and neurological deficits&#44; at times irreversible&#44; and its mortality is approximately 5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The Spanish publications of case series of IS have been few in recent years&#44; during which IS appears to have undergone significant changes in its clinical&#8211;epidemiological characteristics&#46; The aim of this study was to describe the epidemiological&#44; clinical and etiological characteristics and outcomes of patients who have presented IS in 2 hospitals of Palma de Mallorca&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A series of retrospective cases conducted in 2 hospitals on the island of Mallorca that cover a population of approximately 550&#44;000 inhabitants&#46; We included all patients over 15 years of age with a diagnosis of IS from January 1&#44; 2003 to October 31&#44; 2013&#46; The data were obtained from the diagnostic coding database of the department of clinical archives and documentation of the 2 hospitals&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A diagnosis of IS was established when there was a compatible clinical condition &#40;lumbar pain&#44; fever and muscle pain during the physical examination&#41;&#44; supported by an imaging technique&#58; &#40;a&#41; plain radiography with vertebral endplate disintegration&#44; reduced joint space or vertebral body destruction&#59; &#40;b&#41; computed axial tomography &#40;CT scan&#41; with subchondral bone destruction&#44; loss of cortical margin of the vertebral endplate or periosteal reaction&#59; &#40;c&#41; magnetic resonance imaging &#40;MRI&#41; with reduced signal of the vertebra and intervertebral disc on T1&#44; increased signal of the vertebra and disc in T2&#44; loss of definition of the vertebral endplate&#59; and &#40;d&#41; bone scintigraphy with tecnecio-99 &#40;GO <span class="elsevierStyleSup">99</span>mTc&#41;&#46; In terms of the etiological diagnosis&#44; we assessed any isolates in blood or in a sample of the focus obtained during surgery or percutaneous puncture&#46; A diagnosis of spondylitis tuberculous was considered the presence of symptoms and radiological compatible findings&#44; along with positive direct smears for bacilli or <span class="elsevierStyleItalic">M&#46; tuberculosis</span> isolates in Lowenstein-Jensen medium with no other bacterial isolate&#46; We also considered a positive PCR for <span class="elsevierStyleItalic">M&#46; tuberculosis</span> of any microbiological sample&#44; a positive tuberculin test or QuantiFERON &#8211; TB Gold<span class="elsevierStyleSup">&#174;</span>&#44; along with clinical and radiological improvement after starting tuberculostatic treatment&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The following variables were collected&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Demographic&#58; age&#44; sex and date of admission&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Predisposing factors&#58; PDU&#44; spinal surgery&#44; previous bacteremia&#44; associated comorbidities according to the Charlson classification and functional state assessed with the Barthel index&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Clinical manifestations&#58; days elapsed from symptom onset to diagnosis&#44; presence of lumbar pain&#44; fever&#44; pain during the physical examination or neurological symptoms &#40;radicular pain&#44; paresthesia&#44; paresis or paralysis&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Results of additional tests&#58; leukocyte count&#44; erythrocyte sedimentation rate &#40;ESR&#41;&#44; C-reactive protein &#40;CRP&#41;&#44; performance of simple radiology&#44; CT scan&#44; MRI or GO <span class="elsevierStyleSup">99</span>mTc&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Microbiological data&#58; results of blood cultures&#44; samples obtained using percutaneous puncture or surgery at the IS focus&#44; recent bacteremia in the last month and&#44; in the case of <span class="elsevierStyleItalic">M&#46; tuberculosis</span> infection&#44; we also collected the results of the tuberculin test&#44; CRP for <span class="elsevierStyleItalic">M&#46; tuberculosis</span> or the <span class="elsevierStyleItalic">QuantiFERON &#8211; TB Gold</span><span class="elsevierStyleSup">&#174;</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment&#58; We assessed the antibiotic treatment&#44; both empiric and targeted and treatment duration&#44; whether intravenous or oral&#44; and recorded the reasons for any change in antibiotic treatment&#46; We also recorded the need and reasons for surgical treatment &#40;including the diagnostic method&#44; medical treatment failure&#44; abscess drainage and bone marrow pressure&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Evolution in the acute phase&#58; presence of chronic cutaneous fistulae and epidural&#44; paravertebral or psoas abscesses&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Follow-up during the first year&#58; presence of sequelae in the form of residual chronic pain or neurological deficiency&#44; as well as the evolution to clinical or microbiological healing&#44; in cases where sequelae were detected&#44; mortality or related overall according to the discretion of the researchers provided there was a direct relationship between the infection and death&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">A basic statistical analysis was conducted using frequency calculation for each qualitative variable and the mean&#44; standard deviation &#40;SD&#41;&#44; median and interquartile range &#40;IQR&#41; for the quantitative variables&#46; We then performed a univariate analysis on the qualitative variables using the chi-squared test &#40;Fisher&#39;s test for those cases that required it&#41;&#44; as well as a risk estimate using the odds ratio calculation with its 95&#37; confidence intervals &#40;95&#37; CI&#41;&#46; For the comparison of quantitative variables&#44; we used Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#46; The level of statistical significance was established at &#46;05 &#40;in all hypothesis testing&#44; the null hypothesis was rejected with an error type I or an alpha error &#60;0&#46;05&#41;&#46; All calculations were performed with the statistical bundle SPSS 12&#46;0 for Windows&#46; The confidentiality of the recorded data was ensured&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 51 cases of IS were recorded&#59; 37 &#40;72&#46;5&#37;&#41; were of men and 14 were of women &#40;27&#46;5&#37;&#41;&#46; The median age was 66 years &#40;IQR&#58; 22&#8211;85&#41;&#44; and 28 patients &#40;54&#46;9&#37;&#41; were older than 65 years&#46; The cumulative incidence was 9 cases&#47;10<span class="elsevierStyleSup">6</span> inhabitants&#47;year&#44; and the mean annual incidence was 5&#46;1 cases&#47;year&#44; with the distribution shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Twenty-three patients &#40;45&#46;1&#37;&#41; presented bacteremia in the 30 days prior to the bone infection diagnosis&#46; The origin of the bacteremia was urinary in 10 &#40;43&#46;5&#37;&#41; patients&#44; catheter in 5 &#40;21&#46;7&#37;&#41; patients&#44; respiratory in 3 &#40;13&#37;&#41; patients&#44; endocardial in 3 &#40;13&#37;&#41; patients and skin or soft tissue in 2 &#40;8&#46;7&#37;&#41; patients&#46; Six patients &#40;11&#46;8&#37;&#41; were PDU and 6 &#40;11&#46;8&#37;&#41; had undergone prior spinal surgery&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The comorbidities present in the patients included in this study are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The median Charlson comorbidity index was 2&#46;8 points &#40;range&#58; 0&#8211;13&#41;&#46; Four &#40;7&#46;8&#37;&#41; patients had severe dependence &#40;Barthel index &#60;35 points&#41;&#44; 9 &#40;17&#46;6&#37;&#41; had mild to moderate dependence &#40;&#62;40 points&#41; and 38 &#40;74&#46;5&#37;&#41; were independent&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The most common presentation was spondylodiscitis in 48 &#40;94&#46;1&#37;&#41; cases&#44; while 2 &#40;3&#46;9&#37;&#41; cases presented spondylitis without discitis&#44; and 1 &#40;1&#46;9&#37;&#41; presented posterior segment infection &#40;vertebral arches and spinous process&#41;&#46; The most common location was the lumbar spine in 30 &#40;58&#46;8&#37;&#41; patients&#44; dorsal in 15 &#40;29&#46;4&#37;&#41; and cervical in 6 &#40;11&#46;8&#37;&#41;&#46; All patients showed a single focal involvement&#44; except for one patient who had cervical and dorsal involvement&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The most common symptom was fever &#40;35 cases&#59; 68&#46;8&#37;&#41;&#44; while 14 &#40;27&#46;5&#37;&#41; patients reported radicular pain&#46; During the examination&#44; 32 &#40;62&#46;7&#37;&#41; patients experienced focal pain on palpation in the area of the lesion&#44; and 10 &#40;19&#46;6&#37;&#41; patients experienced paralysis&#44; paresis or paresthesia&#46; The mean elapsed time from symptom onset to diagnosis was 80&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>125&#46;1 days&#46; Leukocytosis was detected &#40;&#8805;11&#44;000 leukocytes&#47;L&#41; in 22 &#40;43&#46;1&#37;&#41; cases&#44; the median CRP was 14 &#40;1&#8211;320&#41; mg&#47;dL&#44; and the median ESR was 48 &#40;10&#8211;40&#41; mm&#47;h&#46; Thirty-eight &#40;74&#46;5&#37;&#41; plain spine radiographs were performed&#44; 23 &#40;60&#46;5&#37;&#41; of which revealed pathological findings&#46; CT scans were performed on 34 &#40;66&#46;6&#37;&#41; patients&#44; 32 of which revealed pathological findings &#40;94&#46;1&#37;&#41;&#46; MRIs were performed on 46 &#40;90&#46;2&#37;&#41; patients&#44; all of them revealing pathological findings &#40;100&#37;&#41;&#46; GO <span class="elsevierStyleSup">99</span>mTc was performed on 12 &#40;23&#46;5&#37;&#41; patients&#44; with normal results on 2 occasions &#40;16&#46;7&#37;&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The IS had a hematogenous origin in 36 &#40;70&#46;6&#37;&#41; patients&#44; was due to contiguity in 4 &#40;7&#46;8&#37;&#41; patients&#44; was postsurgical or post-trauma in 3 &#40;5&#46;9&#37;&#41; patients and was of unknown origin in 8 &#40;15&#46;7&#37;&#41; patients&#46; Forty-four &#40;86&#46;3&#37;&#41; cases were caused by pyogenic bacteria&#59; <span class="elsevierStyleItalic">M&#46; tuberculosis</span> was isolated in 4 &#40;7&#46;8&#37;&#41; cases&#46; In 3 &#40;5&#46;9&#37;&#41; cases&#44; the causal microorganism could not be determined despite performing a percutaneous puncture on the lesion&#46; For the patients without microbiological isolates&#44; the time to diagnosis was 283&#46;3 days &#40;10&#8211;420&#41;&#44; much longer than the 67&#46;4 &#40;1&#8211;450&#41; days required by the patients with a confirmed etiology &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; Statistically significant differences were not found however in terms of treatment time and sequelae&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The causal agents involved are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The most common microorganism was <span class="elsevierStyleItalic">S&#46; aureus</span> in 23 &#40;52&#46;3&#37;&#41; patients of whom 2 were methicillin-resistant &#40;MRSA&#41;&#44; followed by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> in 6 &#40;13&#46;7&#37;&#41; patients&#44; <span class="elsevierStyleItalic">E&#46; coli</span> in 5 &#40;11&#46;4&#37;&#41;&#44; <span class="elsevierStyleItalic">Salmonella</span> and other enterobacteriaceae in 2 &#40;4&#46;5&#37;&#41;&#44; <span class="elsevierStyleItalic">Enterococcus faecalis</span> in 2 &#40;4&#46;5&#37;&#41;&#44; <span class="elsevierStyleItalic">Bacteroides fragilis</span> in 2 &#40;4&#46;5&#37;&#41;&#44; <span class="elsevierStyleItalic">Streptococcus spp&#46;</span> in 2 &#40;4&#46;5&#37;&#41; and coagulase-negative staphylococci in 2 &#40;4&#46;5&#37;&#41; patients&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Serologies for <span class="elsevierStyleItalic">Brucella</span> &#40;Rose Bengal and total antibodies&#41; were conducted for 10 &#40;5&#46;1&#37;&#41; patients&#44; all of which were negative&#46; In 6 of the 10 &#40;60&#37;&#41; cases&#44; the tuberculin test yielded positive results&#46; A QuantiFERON-TB Gold<span class="elsevierStyleSup">&#174;</span> test was performed in 2 &#40;3&#46;9&#37;&#41; cases&#44; which yielded a positive result in only 1 case&#59; the CRP for <span class="elsevierStyleItalic">M&#46; tuberculosis</span> was positive in only 1 case&#46; Microorganisms were isolated in 7 &#40;87&#46;5&#37;&#41; of the 8 patients who underwent surgery&#44; in 11 &#40;50&#37;&#41; of the 22 who underwent percutaneous puncture and in 27 &#40;65&#46;8&#37;&#41; of the 41 for whom blood cultures were performed&#46; Significant differences were detected when comparing the characteristics of patients with pyogenic germs vs&#46; those for whom no germ could be identified&#46; The former group had a shorter time to diagnosis &#40;61&#46;9 vs&#46; 129&#46;33 days&#59; 95&#37; CI 80&#46;9&#8211;363&#46;3&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; and shorter treatment &#40;40&#46;6 vs&#46; 87&#46;7 days&#59; 95&#37; CI 14&#46;7&#8211;120&#46;1&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; The main differences between the cases of IS included in this study according to whether they had a pyogenic or tuberculous etiology are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Empiric antibiotic treatment was monotherapy for 18 &#40;35&#46;3&#37;&#41; patients&#44; double therapy for 20 &#40;39&#46;2&#37;&#41; and triple therapy for 4 &#40;7&#46;8&#37;&#41; patients&#46; No empiric treatment was administered to 9 &#40;17&#46;6&#37;&#41; patients&#46; The empirically administered antibiotics were cloxacillin in 15 cases &#40;21&#46;1&#37;&#41;&#44; vancomycin in 12 &#40;16&#46;9&#37;&#41;&#44; aminoglycosides in 9 &#40;12&#46;7&#37;&#41;&#44; other penicillins in 9 &#40;12&#46;7&#37;&#41;&#44; cephalosporins in 8 &#40;11&#46;3&#37;&#41;&#44; rifampicin on 5 &#40;7&#37;&#41;&#44; carbapenems in 4 &#40;5&#46;6&#37;&#41;&#44; quinolones in 3 &#40;4&#46;2&#37;&#41;&#44; linezolid in 2 &#40;2&#46;8&#37;&#41;&#44; tuberculostatic agents in 2 &#40;2&#46;8&#37;&#41;&#44; daptomycin in 1 &#40;1&#46;4&#37;&#41; and teicoplanin in 1 &#40;1&#46;4&#37;&#41; case&#46; The treatment was changed for 42 &#40;82&#46;3&#37;&#41; patients&#46; For 11 of these patients &#40;26&#46;2&#37;&#41;&#44; the treatment was adjusted based on the results of the antibiogram&#59; the reason for changing treatment in the remaining patients was not reported or specified in the comments of the medical history&#46; The antibiotics most frequently used as targeted treatment were quinolones in 17 &#40;24&#46;3&#37;&#41; cases&#44; cloxacillin in 14 &#40;20&#37;&#41;&#44; rifampicin in 13 &#40;18&#46;6&#37;&#41;&#44; cephalosporins in 7 &#40;10&#37;&#41;&#44; other penicillins in 6 &#40;8&#46;6&#37;&#41;&#44; aminoglycosides in 4 &#40;5&#46;7&#37;&#41;&#44; carbapenems in 3 &#40;4&#46;3&#37;&#41;&#44; vancomycin in 3 &#40;4&#46;3&#37;&#41;&#44; linezolid in 1 &#40;1&#46;4&#37;&#41;&#44; clindamycin in 1 &#40;1&#46;4&#37;&#41; and teicoplanin in 1 &#40;1&#46;4&#37;&#41; case&#46; Of the 6 &#40;11&#46;7&#37;&#41; patients who underwent empirical treatment with tuberculostatic agents&#44; <span class="elsevierStyleItalic">M&#46; tuberculosis</span> was isolated in 4&#46; No IS-causing microorganism could be isolated in the 2 remaining patients&#44; although they progressed favorably with no complications during the follow-up&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The mean total treatment time was 78&#46;92 days &#40;SD&#44; 66&#46;4&#41;&#46; Antibiotic treatment was administered intravenously for 29&#46;64 days &#40;SD&#44; 16&#46;1&#41; and orally for 71&#46;61 days &#40;SD&#44; 75&#46;3&#41;&#46; The cases of IS of tuberculosis origin were treated for 212 days &#40;SD&#44; 75&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Twelve patients &#40;23&#46;5&#37;&#41; required some type of surgical management&#59; 5 &#40;41&#46;6&#37;&#41; for abscess draining&#44; 5 &#40;41&#46;6&#37;&#41; for spinal decompression&#44; 1 &#40;8&#46;3&#37;&#41; due to treatment failure and 1 &#40;8&#46;3&#37;&#41; for diagnostic purposes&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">During the acute phase&#44; 12 patients &#40;23&#46;5&#37;&#41; developed paravertebral abscesses&#44; 8 &#40;15&#46;7&#37;&#41; developed epidural abscesses and 3 &#40;5&#46;9&#37;&#41; developed psoas abscesses&#46; Seven patients &#40;13&#46;7&#37;&#41; presented long-term residual neurological deficits and 6 &#40;11&#46;8&#37;&#41; maintained chronic pain&#46; Thirty-six patients &#40;70&#46;6&#37;&#41; were clinically cured&#44; 4 &#40;7&#46;8&#37;&#41; presented sequelae despite demonstrating microbiological healing&#44; and another 6 &#40;11&#46;8&#37;&#41; died&#44; although only one of them died for reasons directly related to the infection&#46; Due to an inability to maintain clinical follow-up&#44; we were not able to determine the outcome of 5 &#40;9&#46;8&#37;&#41; patients&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The patients who presented acute complications or long-term sequela presented comorbidities &#40;median Charlson&#39;s index of 4 points &#91;IQR 0&#8211;13&#93; vs&#46; 2 points &#91;IQR 0&#8211;11&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;068&#41;&#44; neurological symptoms at symptom onset &#40;14 &#91;58&#46;3&#37;&#93; vs&#46; 3 &#91;11&#46;1&#37;&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41; and required surgery &#40;10 &#91;83&#46;3&#37;&#93; vs&#46; 2 &#91;6&#46;2&#37;&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41;&#44; with a greater frequency than the other patients who did not present acute complications or long-term sequelae&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">This study describes the main clinical and epidemiological characteristics of 51 cases of IS that required hospitalization and were treated in 2 hospital centers in Mallorca between 2003 and 2013&#46; This study represents the third largest Spanish series&#44; in terms of the number of included patients&#44; published in the last 10 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2&#44;6&#44;9&#44;10</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In our study&#44; the incidence of IS was 9 cases<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span> inhabitants&#47;year&#44; the same rate reported more recently by Ruiz Mart&#237;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> and similar to the largest series reported in Spain by Colmenero et al&#46;&#44; <a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> who observed an incidence of 7 cases<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span> inhabitants&#47;year&#46; These results indicate that despite the increase in the incidence reported by a number of authors&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> the incidence in our community has not changed significantly&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The disease antecedents that have classically been related to IS&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> such as diabetes mellitus&#44; liver disease&#44; neoplasms and immunosuppression&#44; are also the most common in our series&#46; Although 54&#46;9&#37; of the patients were older than 65 years&#44; as can be deduced from the estimates of the Charlson and Barthel indices&#44; they did not present a significant degree of comorbidity&#44; and 74&#46;5&#37; of the patients were completely independent&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The most common location for IS was lumbar&#46; The clinical condition was characterized by the presence of fever&#44; focal pain in the lesion and&#44; in a significant minority of cases &#40;19&#46;6&#37;&#41;&#44; focal neurological impairment in the form of paralysis&#44; paresis&#44; algias or paresthesia&#46; This high percentage could be related to the delay from symptom onset to diagnosis that occurred in our series&#46; The additional tests included detecting the presence of leukocytosis&#44; increased PCR and ESR&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The diagnostic sensitivities of the spine imaging tests were 60&#46;5&#37; for the plain radiology&#44; 83&#46;3&#37; for the GO <span class="elsevierStyleSup">99</span>mTc&#44; 94&#46;1&#37; for the CT scan and 100&#37; for the MRI&#44; results very similar to those reported previously&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2&#44;9</span></a> except for the plain radiography&#44; which could be due to the difficulty in interpreting the often nonspecific radiological changes&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The origin of the IS was mostly hematogenous&#46; In our series&#44; only 3 patients had previously undergone surgery&#44; which differs from previous observations&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> In most cases&#44; the IS was caused by pyogenic germs &#40;86&#46;3&#37;&#41;&#44; with monobacterial isolates in all cases&#46; The most common microorganism was <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;52&#46;3&#37;&#41;&#44; coinciding with the findings of other series&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;6&#44;10</span></a> The presence of MRSA was not a noteworthy aspect of our series &#40;only 2 cases had MRSA&#41;&#44; in contrast to that observed in other series that found increases in its incidence&#44; which were hypothetically related to hospital care&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> Although the incidence in 2012 of <span class="elsevierStyleItalic">M&#46; tuberculosis</span> infection in all of its clinical forms in the Balearic Islands was 12&#46;8 cases per 100&#44;000 inhabitants&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> the number of cases of tuberculous IS has been low&#44; given that the latest case was diagnosed in 2008&#46; It is worth noting that in our series there was no case of IS caused by <span class="elsevierStyleItalic">Brucella</span> and that since 2010 the Balearic Islands have been considered by the European Union as a territory unscathed by bovine and caprine brucellosis&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Our results support the diagnostic yield of percutaneous punctures and&#44; when necessary&#44; surgical approaches&#44; enabling accurate microbiological diagnoses to be reached&#44; which in turn enable the most appropriate treatment to be administered&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In our series&#44; 17&#46;6&#37; of the cases started antibiotherapy empirically until the microorganism responsible for the infection was identified&#46; In the majority of cases&#44; empiric antibiotherapy was likely started due to the presence of fever and nonspecific symptoms&#44; a situation that could have been accompanied by reduced diagnostic yields&#46; Although the current trend is to decrease the antibiotic treatment duration&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> there is controversy given that the duration depends fundamentally on the microbiological isolate&#44; the presence of bacteremia&#44; the presence of endocarditis&#44; paravertebral abscesses that require drainage&#44; the patient&#39;s general condition&#44; etc&#46; To start empiric antibiotherapy&#44; it is important to characterize the various clinical conditions&#46; In our study&#44; the comparisons performed between the various etiologies show that spondylodiscitis of pyogenic origin has a higher frequency of previous bacteremia and is diagnosed earlier than spondylodiscitis of tuberculosis or unidentified origin&#46; We also have no randomized clinical trials&#44; and the current recommendations range from 6 weeks<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a> to 3 months&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> with an intravenous treatment duration of at least 4 weeks&#46; In our study&#44; the patients underwent treatment for 78&#46;92 days&#44; of which intravenous administration used 29&#46;64 days&#46; All patients with IS of tuberculosis origin underwent treatment for at least 6 months&#44; according to the recommendations of the treatment guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In our series&#44; almost half of the patients presented localized complications during the acute phase&#46; As occurred in other series&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2</span></a> mortality was low&#44; although morbidity was high given that chronic pain or residual neurological deficits were detected in almost a quarter of the cases during follow-up&#44; which compromised the patients&#8217; quality of life&#46; It is possible that a greater index of suspicion and a shorter delay in the diagnosis of IS could reduce these types of complications&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Our study&#39;s limitations include its retrospective nature&#46; Selecting cases according to the coding of the discharge report could have led us to underestimate the number of cases&#44; due to errors in the preparation or coding of the report&#46; However&#44; it seems fairly unlikely given the characteristics of IS&#46; The intervention by various specialists from 2 hospital centers&#44; with no homogeneous diagnostic and therapeutic criteria&#44; could have affected our results&#46; The collection of samples using percutaneous puncture was conducted by different physicians in the department of radiology and was guided by ultrasonography or CT&#46; We therefore cannot ensure that the method for collecting samples was the same in all cases&#46; We cannot rule out the fact that during the follow-up &#40;after discharge&#41; a number of patients were treated in other hospital centers&#44; both public and private&#44; although this number is probably low given that the participating hospitals are the centers that treat the largest percentage of the population in Mallorca&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">We can conclude that the incidence of IS has not changed significantly over the last decade&#44; a fact that can be observed mainly in patients with associated comorbidity &#40;although without a high degree of dependence&#41;&#46; The main etiology of IS is <span class="elsevierStyleItalic">S&#46; Aureus</span>&#44; which usually presents a long diagnostic delay and&#44; although it causes low mortality&#44; frequently causes disabling sequelae&#46; The selective performance of percutaneous punctures&#44; accompanied by blood cultures&#44; improves the diagnostic performance&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2014-11-10"
    "fechaAceptado" => "2015-01-20"
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          "clase" => "keyword"
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            0 => "Bone diseases"
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            2 => "Spondylitis"
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            0 => "Enfermedades &#243;seas"
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            2 => "Espondilitis"
            3 => "Discitis"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Vertebral osteomyelitis &#40;VO&#41; is a rare entity&#44; although its incidence has increased in recent years&#46; The objective is to describe the patients with this infection in our environment and a comparison with other published series&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective review was conducted of epidemiological&#44; clinical&#44; microbiological&#44; treatment&#44; complications and evolution data of patients with VO during 10 years &#40;2004&#8211;2014&#41; in two hospitals of Mallorca&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">51 cases&#44; median age 66 &#40;range 22&#8211;85&#41; years&#44; 37 &#40;72&#46;5&#37;&#41; men with a mean onset of symptoms of 80&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>125&#46;1 days&#46; In thirty-six &#40;70&#46;6&#37;&#41; cases the origin of infection was considered hematogenous&#44; although previous bacteremia was documented in 23 &#40;45&#37;&#41; cases&#44; being of urinary in 10 &#40;43&#46;5&#37;&#41; cases&#46; Clinically at the moment of diagnosis 35 &#40;68&#46;8&#37;&#41; had fever&#44; 32 &#40;62&#46;7&#37;&#41; pain&#44; 14 &#40;27&#46;5&#37;&#41; irradiated nerve pain and 10 &#40;19&#46;6&#37;&#41; paralysis&#47;paresia&#46; MRI was the most performed radiological test 46 &#40;90&#46;2&#37;&#41;&#44; being pathological in all cases&#46; <span class="elsevierStyleItalic">Staphylococcus aureus</span> 23 &#40;52&#46;3&#37;&#41; was the most common microbiological isolates&#46; At the moment of the diagnosis&#44; blood cultures were positive in 27 &#40;65&#46;8&#37;&#41; of 41 cases and 11 &#40;50&#37;&#41; of 22 percutaneous puncture was positive&#46; Paraspinal&#44; epidural or psoas abscesses were observed in 23 &#40;45&#46;1&#37;&#41;&#44; neurological deficit in 7 &#40;13&#46;7&#37;&#41; and chronic pain in 6 &#40;11&#46;8&#37;&#41;&#46; One patient &#40;1&#46;9&#37;&#41; died in relation with infection&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnosis was delayed in most cases&#46; Previous bacteremia being main predisposing factor and hematogenous origin the main source of infection&#46; <span class="elsevierStyleItalic">S&#46; aureus</span> was the most isolated&#46; Percutaneous puncture together with blood cultures increase etiologic diagnosis&#46; A high percentage of patients had complications or sequelae&#46;</p></span>"
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            "titulo" => "Introduction"
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            "titulo" => "Methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La espondilitis infecciosa &#40;EI&#41; es una entidad poco frecuente cuya incidencia ha aumentado en los &#250;ltimos a&#241;os&#46; El objetivo de este estudio ha sido describir los casos con EI y realizar una comparaci&#243;n con el resto de series publicadas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo donde se describen datos epidemiol&#243;gicos&#44; microbiol&#243;gicos y cl&#237;nicos de los pacientes diagnosticados de EI durante un periodo de 10 a&#241;os &#40;2004-2014&#41; en 2 hospitales de Mallorca&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; un total de 51 pacientes&#44; con una edad mediana de 66 a&#241;os &#40;rango 22-85&#41;&#46; El 72&#44;5&#37; &#40;37&#47;51&#41; fueron varones&#46; El tiempo medio transcurrido desde el inicio de la cl&#237;nica hasta el diagn&#243;stico fue de 80&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>125&#44;1 d&#237;as&#46; En 36 ocasiones &#40;70&#44;6&#37;&#41; el origen fue hemat&#243;geno&#46; El factor predisponente m&#225;s frecuente fue presentar bacteriemia previa &#40;10 &#91;43&#44;5&#37;&#93; de origen urinario&#41;&#46; Presentaron fiebre 35 pacientes &#40;68&#44;8&#37;&#41;&#44; dolor 32 &#40;62&#44;7&#37;&#41;&#44; radiculalgia 14 &#40;27&#44;5&#37;&#41; y par&#225;lisis&#47;paresia 10 &#40;19&#44;6&#37;&#41;&#46; La prueba diagn&#243;stica m&#225;s utilizada fue la resonancia magn&#233;tica &#40;46 &#91;90&#44;2&#37;&#93;&#41;&#44; resultando patol&#243;gica en todos los casos&#46; El microorganismo etiol&#243;gico m&#225;s frecuente fue <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;23 &#91;52&#44;3&#37;&#93;&#41;&#46; Los hemocultivos resultaron positivos en 27&#47;41 ocasiones &#40;65&#44;8&#37;&#41; y la punci&#243;n percut&#225;nea en 11&#47;22 &#40;50&#37;&#41;&#46; Veintitr&#233;s pacientes &#40;45&#44;1&#37;&#41; desarrollaron abscesos paravertebrales&#44; epidurales o del psoas&#44; 7 &#40;13&#44;7&#37;&#41; d&#233;ficits neurol&#243;gicos residuales y 6 &#40;11&#44;8&#37;&#41; dolor cr&#243;nico&#46; Un paciente &#40;1&#44;9&#37;&#41; falleci&#243; por motivos relacionados con la infecci&#243;n&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La EI es poco frecuente&#46; Su origen usualmente es hemat&#243;geno&#46; La bacteriemia previa es el factor predisponente m&#225;s importante&#46; El diagn&#243;stico es habitualmente tard&#237;o&#44; siendo <span class="elsevierStyleItalic">Staphylococcus aureus</span> el germen implicado con mayor frecuencia&#46; La realizaci&#243;n de punciones percut&#225;neas acompa&#241;ando a los hemocultivos aumenta la rentabilidad diagn&#243;stica&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Raya Cruz M&#44; Vilchez Rueda HH&#44; Marinescu CI&#44; Saras&#237;bar Ezcurra H&#44; Riera Jaume M&#44; Payeras Cifre A&#46; Espondilitis infecciosa en Baleares&#58; an&#225;lisis de 51 casos&#46; Rev Clin Esp&#46; 2015&#59;215&#58;251&#8211;257&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Annual incidence of cases of spondylodiscitis in Mallorca &#40;2004&#8211;2013&#41;&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antecedent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frequency &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sex &#40;male&#47;female&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;72&#46;5&#41;&#47;14 &#40;27&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;23&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Neoplastic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;15&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chronic liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;13&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chronic respiratory disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;11&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chronic heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Peripheral arterial disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chronic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ischemic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chronic cerebrovascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hemiplegia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gastroduodenal ulcer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acquired immune deficiency syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hematologic neoplastic disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Connective tissue disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blood cultures&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percutaneous sample&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical sample&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;36&#46;6&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;55&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Escherichia coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#46;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Coagulase-negative staphylococci&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Salmonella</span> and other Enterobacteriaceae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Enterococcus faecalis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;4&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Bacteroides fragilis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;9&#46;1&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;34&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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            ]
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              "identificador" => "tblfn0010"
              "etiqueta" => "b"
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            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">In 1 case&#44; <span class="elsevierStyleItalic">Enterococcus faecalis</span> was isolated in blood cultures by bacteremia prior to the current episode&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">In 1 case&#44; the organism was isolated in the surgical sample and in the percutaneous puncture</p>"
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          ]
        ]
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Isolated pyogenic microorganisms in the 51 cases of spondylodiscitis included in the study&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;038 &#40;1&#46;04&#8211;1&#46;48&#41;&nbsp;\t\t\t\t\t\t\n
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Differences between the cases of pyogenic and tuberculous etiology in the 51 cases of spondylodiscitis included in the study&#46;</p>"
        ]
      ]
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        "tipo" => "MULTIMEDIATEXTO"
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        "mostrarDisplay" => true
        "texto" => array:1 [
          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">What we know&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Infectious spondylitis is a low-incidence disease&#46; Few series with multiple cases have been published in recent years&#44; and it is possible that significant changes are occurring in its clinical&#8211;epidemiological characteristics&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">What this article provides&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">The incidence of infectious spondylitis in our community remains stable&#46; The main etiological agent of this disease is <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#46; The involvement of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> is very low and that of <span class="elsevierStyleItalic">Brucella melitensis</span> has disappeared completely&#46; The selective performance of percutaneous punctures&#44; accompanied by blood cultures&#44; has appreciably improved diagnostic performance&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Editors</p></span></span>"
        ]
      ]
    ]
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      "titulo" => "References"
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        0 => array:2 [
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            0 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Espondilodiscitis infecciosas en un &#225;rea sanitaria gallega&#44; 1983&#8211;2003"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "N&#46; G&#243;mez Rodr&#237;guez"
                            1 => "Y&#46; Penelas-Cort&#233;s Bellas"
                            2 => "J&#46; Ib&#225;&#241;ez Ru&#225;n"
                            3 => "M&#46; Gonz&#225;lez P&#233;rez"
                            4 => "M&#46;L&#46; S&#225;nchez Lorenzo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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                ]
              ]
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            1 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "2"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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                            0 => "J&#46;M&#46; Ruiz Mart&#237;n"
                            1 => "S&#46; Ros Exp&#243;sito"
                            2 => "A&#46; Montero S&#225;ez"
                            3 => "P&#46; Sanz Frutos"
                          ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.reuma.2009.05.003"
                      "Revista" => array:6 [
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                        "volumen" => "6"
                        "paginaInicial" => "86"
                        "paginaFinal" => "90"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21794687"
                            "web" => "Medline"
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            ]
            2 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Spondylodiscitis&#58; update on diagnosis and management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46; Gouliouris"
                            1 => "S&#46;H&#46; Aliyu"
                            2 => "N&#46;M&#46; Brown"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "2010"
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            ]
            3 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Current diagnosis and treatment of spondylodiscitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Sobottke"
                            1 => "H&#46; Seifert"
                            2 => "G&#46; F&#228;tkenheuer"
                            3 => "M&#46; Schmidt"
                            4 => "A&#46; Gossmann"
                            5 => "P&#46; Eysel"
                          ]
                        ]
                      ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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            4 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical practice&#46; Vertebral osteomyelitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "W&#46; Zimmerli"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMcp0910753"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2010"
                        "volumen" => "362"
                        "paginaInicial" => "1022"
                        "paginaFinal" => "1029"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20237348"
                            "web" => "Medline"
                          ]
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                      ]
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              ]
            ]
            5 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The management and outcome of spinal implant infections&#58; contemporary retrospective cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "T&#46;J&#46; Kowalski"
                            1 => "E&#46;F&#46; Berbari"
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                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/512194"
                      "Revista" => array:6 [
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2015.03.002

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