P0265SPONDYLODISCITIS IN HEMODIALYSIS PATIENTS: A NEW EMERGING DISEASE? DATA FROM AN ITALIAN CENTER
Authors: Traversi Lara , Nava Elisa , Xhaferi Brunilda , Tedoldi Silvia , Mazzullo Tiziana , Martino Stefania , Bigatti Giada Giovanna Olga , Ciurlino Daniele , Bertoli Silvio 
Published: June 2020

Abstract

Background and Aims
Hemodialysis (HD) patients represent a risk category for infections and for their possible complications, in particular infective spondylodiscitis. Although this is a serious complication, only few cases have been reported in the literature and it is not clear which is the best clinical management.
The aim of this retrospective study was to evaluate the cases of infective spondylodiscitis that occurred among HD patients of our center.

Method
We collected the cases of spondylodiscitis that occurred at our center between May 2005 and October 2019. We focused in particular on the time interval between onset of symptoms and diagnosis, often delayed. The possible risk factors related to the onset of this disease were also considered. The diagnosis of infective spondylodiscitis was based on clinical data, laboratory results and diagnostic imaging tests.

Results
Over more than 10 years, there were 9 cases. The mean age was 69 ± 12 years. 55.6% of patients were affected by diabetes mellitus, 55.6% by hypertension, 22.2% by bone diseases, 11.1% by cancer and 11.1% by rheumatoid arthritis in chronic treatment with low-dose steroids and azathioprine (Table 1).
All patients had back pain as an initial symptom, 55.6% had fever, while 33.4% had neurological symptoms. At hospital admission 55.6% of patients had leukocytosis and 88.9% of patients had elevated CRP level (Table 2).
Six patients (66.7%) had their diagnoses confirmed by magnetic resonance imaging (MRI), while two patients had performed CT prior to MRI and one patient had his diagnosis confirmed by CT (Table 2). The lumbar region was the most common site of infection (77.8%) (Figure 1).
The mean dialytic age was 33 ± 38 months. Four patients used an arteriovenous fistula as vascular access for HD, one patient used an arteriovenous graft, three patients used a tunneled cuffed catheter, and one patient used a temporary catheter (Table 3). Two patients had experienced thrombosis of the arteriovenous fistula requiring endovascular surgery.
Blood culture were positive in five patients (four for S. aureus and one for S. agalactiae) and negative in four patients. Three of the patients with positive coltures used a catheter for HD and in two cases it was necessary its removal. Bone biopsy (performed in three cases) confirmed the diagnosis of S. aureus spondylodiscitis in one patient (Table 3).
The mean time interval between onset of symptoms and diagnosis was 34 ± 42 days (Table 3).
All patients received antibiotic treatment for a mean duration of 6 weeks. In most of the cases it was used vancomycin or teicoplanin plus ciprofloxacin as initial antibiotics (Table 4).
One patients had recurrent infective spondylodiscitis within 2 years; one patient had long-term neurologic sequelae despite surgical treatment. The others 7 cases underwent resolution after a mean of 3.5 months.

Conclusion
Infective spondylodiscitis is a disease to be suspected in the presence of back pain among HD patients, even in the absence of fever or traditional risk factors. It is important to get an early diagnosis, to improve the outcome of patients, avoiding diagnostic delays. Close monitoring of vascular access, paying attention to disinfection procedures and aseptic techniques, is important to avoid this complication.
Figure 1. MRI of the lumbosacral spine without gadolinium contrast showing discitis at the L4–L5 level (Patient n. 6). Table 1. Characteristics of the patients with infective spondylodiscitis in care at our center. Table 2. Initial clinical presentation, initial laboratory results, diagnostic tools, location of infection. Table 3. Dialytic age, vascular access for hemodialysis, culture results, time interval between onset of symptoms and diagnosis. Table 4. Treatments and outcome of patients.