Monitoring
A patient typically should be monitored for recurrence of infection and side effects from antimicrobial and other medications. In patients with native vertebral osteomyelitis, systemic inflammatory markers (erythrocyte sedimentation rate, C-reactive protein) should be monitored after approximately 4 weeks of antimicrobial therapy, in conjunction with a clinical assessment. Unchanged or increasing values after 4 weeks of treatment should increase suspicion for treatment failure.[13] Follow-up magnetic resonance imaging is advised to assess evolutionary changes of the epidural and paraspinal soft tissues in patients with native vertebral osteomyelitis who are judged to have a poor clinical response to therapy.[13] In patients with native vertebral osteomyelitis and clinical and radiographic evidence of treatment failure, the Infectious Diseases Society of America (IDSA) suggests obtaining additional tissue samples for microbiologic (bacteria, fungal, and mycobacterial) and histopathologic examination, either by image-guided aspiration biopsy or through surgical sampling.[13] In these cases, the IDSA recommends consultation with a spine surgeon and an infectious disease physician.[13]
If the decision is to use intravenous antibiotic treatment for up to 6 weeks, the patient should be discharged only if there is a formal outpatient antibiotic therapy service available (in conjunction with a primary care service) with appropriate patient selection, vascular access devices and insertion, 24-hour supervision available, adequate blood monitoring, mechanisms for dealing rapidly with complications, and formal clinical governance structures. For children with suspected or documented osteomyelitis who respond to initial intravenous antibiotic therapy, transition to an oral antibiotic regimen rather than outpatient parenteral antibiotic therapy (OPAT) is recommended when an appropriate (active against the confirmed or presumed pathogens) and well-tolerated oral antibiotic option is available.[4]
Monitoring of oral therapy can be performed by the primary care doctor in the community if feasible. The frequency of monitoring depends on the duration of disease, the surgical management undertaken, comorbidities, and the complexity of antimicrobial treatment. It should be individualized.
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