Review Article

Bacteroides fragilis Vertebral Osteomyelitis: Case Report and a Review of the Literature

Authors: Hesham Elgouhari, MD, Mohamed Othman, MD, Wendy H. Gerstein, MD

Abstract

Background: To review the presentation of Bacteroides fragilis (B fragilis) spondylodiscitis.


Methods: Two investigators independently searched the published English, Spanish and French languages literature through September 2005 using MEDLINE (1966–2005). We included all reported cases of vertebral osteomyelitis or spondylodiscitis caused by B fragilis, not related to sacral decubitus ulcers, in adults (age 16 yr and above). A third author independently reviewed all articles and extracted data for accuracy. The final pool of eligible publications included 11 articles, publication dates ranging from 1978 to 2005. Eight were written in English, two in Spanish, and one in French.


Results: The age of the patients in this series ranged from 17 to 74 years, with a mean age of 55 years. Male to female ratio was 6:1. Lumbar involvement was reported in nine cases, thoracic involvement in two patients and sacral involvement in one patient. B fragilis was recovered by blood culture in four patients and by tissue culture in eight patients. Metronidazole was the most common antibiotic used for treatment (eight patients), either as monotherapy or in combination with other antibiotics.


Conclusions: B fragilis is a rare causative agent of spondylodiscitis, but it should be considered in patients with spondylodiscitis who have contiguous intraabdominal or pelvic infections or who had recent gastrointestinal procedures that may have led to B fragilisbacteremia.


Key Points


* Bacteroides fragilis is a rare causative agent of spondylodiscitis. It should be considered in patients with spondylodiscitis who have contiguous intraabdominal or pelvic infections, or who had recent gastrointestinal procedures.


* Presentation of spondylodiscitis commonly includes back pain. Less than half of the patients will have fever or neurological deficits.


* A needle biopsy is the gold standard for the diagnosis.


* More than 95% of Bacteroides fragilis are susceptible to metronidazole.


* In recent years, B fragilis has shown increasing resistance to clindamycin.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis 1979;1:754–776.
 
2. Sapico FL, Montgomerie JZ. Vertebral osteomyelitis. Infect Dis Clin North Am 1990;4:539–550.
 
3. Perronne C, Saba J, Behloul Z, et al. Pyogenic and tuberculous spondylodiskitis (vertebral osteomyelitis) in 80 adult patients 1994;19:746–750.
 
4. Honan M, White GW, Eisenberg GM. Spontaneous infectious discitis in adults. Am J Med1996;100:85–89.
 
5. Beigelman PM, Rantz LA. Clinical significance of Bacteroides. Arch Intern Med 1949;84:605–611.
 
6. Saeed MU, Mariani P, Martin C, et al. Anaerobic spondylodiscitis: case series and systematic review. South Med J 2005;98:144–148.
 
7. Sexton DJ McDonald M. Vertebral Osteomyelitis. www.uptodate.com, version 13.2. Accessed March 2, 2007.
 
8. Levine DP, Brown PD. Infections in injection drug users. In: Mandell, GL, Bennett JE, Dolin R.Principles and Practice of Infectious Diseases. 6th edition. Vol 2. Philadelphia, Elsevier Inc, 2005, pp 3462–3465.
 
9. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 2002;34:1342–1350.
 
10. Raff MJ, Melo JC. Anaerobic osteomyelitis. Medicine (Baltimore) 1978;57:83–103.
 
11. Lewis RP, Sutter VL, Finegold SM. Bone infections involving anaerobic bacteria. Medicine (Baltimore) 1978;57:279–305.
 
12. Brook I, Frazier EH. Anaerobic osteomyelitis and arthritis in a military hospital: a 10-year experience. Am J Med 1993;94:21–28.
 
13. Chazan B, Strahilevitz J, Millgram MA, et al. Bacteroides fragilis vertebral osteomyelitis secondary to anal dilatation. Spine 2001;26:E377–E378.
 
14. Beaumont S, Winer A, Demeure D, et al. [Parasigmoid abscess revealed by anaerobic osteomyelitis] (in French). Ann Fr Anesth Reanim 2000;19:474–477.
 
15. Merine D, Fishman EK, Magid D. CT detection of sacral osteomyelitis associated with pelvic abscesses. J Comput Assist Tomogr 1988;12:118–121.
 
16. Toral Revuelta JR, Llobell Segui G, Peralba Vano JI, Martinez Ruiz M. [Psoas abscess associated to vertebral osteomyelitis and Bacteroides fragilis bacteremia following lower digestive tract endoscopy] (in Spanish). Med Clin (Barc). 1994;102:597–598.
 
17. Bilgrami S, Pesanti EL, Singh NT, et al. Spinal cord compression due to anaerobic vertebral osteomyelitis in a patient with metastatic prostate cancer. Clin Infect Dis 1995;21:457–458.
 
18. Boutoille D, Talarmin JP, Prendki V, Raffi F. Hematogenous anaerobic vertebral osteomyelitis due to Bacteroides fragilis in a diabetic patient. Eur J Intern Med 2003;14:63–64.
 
19. Santin M, Carratala J, Ariza X. [Hematogenous spondylitis caused by Bacteroides fragilis] (in Spanish). Enferm Infecc Microbiol Clin 1992;10:380–381.
 
20. Tsuji Y, Okita Y, Niwaya K, et al. Allograft replacement of common iliac artery mycotic aneurysm caused by Bacteroides fragilis vertebral spondylitis: a case report. Vasc Endovascular Surg 2003;37:441–444.
 
21. Doita M, Marui T, Kurosaka M, et al. Contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis. Spine 2001;26:E303–E307.
 
22. Feng J, Austin TW. Anaerobic vertebral osteomyelitis. CMAJ 1991;145:132–133.
 
23. Finegold SM. Host factors predisposing to anaerobic infections. FEMS Immunol Med Microbiol 1993;6:159–163.
 
24. Finkelstein R, Nachum Z, Reissman P, et al. Anaerobic osteomyelitis in patients with Gaucher’s disease. Clin Infect Dis 1992;15:771–773.
 
25. Dodd MJ, Griffiths ID, Freeman R. Pyogenic arthritis due to Bacteroides complicating rheumatoid arthritis. Ann Rheum Dis 1982;41:248–249.
 
26. Ryeen AC, Schean A, Agell BO. A case of septic arthritis in multiple joints due to Bacteroides fragilis in a patient with rheumatoid arthritis. Acta Orthop Scand 1978;49:98–101.
 
27. Calvo JM, Ramos JL, García F, et al. Pyogenic and non-pyogenic vertebral osteomyelitis: descriptive and comparative study of a series of 40 cases. Enferm Infecc Microbiol Clin 2000;18:452–456.
 
28. Beronius M, Bergman B, Andersson R. Vertebral osteomyelitis in Goteborg, Sweden: a retrospective study of patients during 1990-95. Scand J Infect Dis 2001;33:527–532.
 
29. Patzakis MJ, Rao S, Wilkins J, et al. Analysis of 61 cases of vertebral osteomyelitis. Clin Orthop Relat Res 1991;264:178–183.
 
30. Aldridge KE, Ashcraft D, Cambre K, et al. Multicenter survey of the changing in vitro antimicrobial susceptibilities of clinical isolates of Bacteroides fragilis group, Prevotella, Fusobacterium, Porphyromonas, and Peptostreptococcus species. Antimicrob Agents Chemother 2001;45:1238–1243.
 
31. Teng LJ, Hsueh PR, Tsai JC, et al. High incidence of cefoxitin and clindamycin resistance among anaerobes in Taiwan. Antimicrob Agents Chemother 2002;46:2908–2913.