akinohanayuki ブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

化膿性脊椎炎の治療期間

化膿性脊椎炎の治療期間に関する報告がLancetにありました。

 

Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial

P : aged 18 years or older with microbiologically confirmed pyogenic vertebral osteomyelitis and typical radiological features from 71 medical care centres across France.

E :  6 weeks ; 176 patients

C : 12 weeks of antibiotic treatment ;  175 patients

O :  clinical cure ; The difference between the groups (0·05%, 95% CI −6·2 to 6·3) showed the non-inferiority of the 6-week regimen when compared with the 12-week regimen.

T :  open-label, non-inferiority, randomised controlled trial

 

投与期間は、試験しないと結果分からないですね。

倫理的に難しいですが、良い結果が得られれば、

世界が変わる一歩となりえます。

 

 

なお、糖尿病など既往ある場合、投与期間が難しいと感じるこの頃

DFOの投与期間報告が最近あったので、疾患は異なりますが参考にして行きたいですね。

 

Six-week versus twelve-week antibiotic therapy for nonsurgically treated diabetic foot osteomyelitis: a multicenter open-label controlled randomized study.

 

P : patients with DFO treated nonsurgically (i.e., antibiotics alone)

E :  6- week duration of antibiotic treatment ; 20patients

C :  12-week duration of antibiotic treatment ; 20patients

O :  no significant differences between patients treated for 6 versus 12 weeks (12/20 vs. 14/20, respectively; P = 0.50). 

T : prospective randomized trial

 

人数少ないですが、差がなかったRCT。

12/20 (60%) vs. 14/20 (70%)と、統計学有意差はありませんでしたが

12週間の方が70%なんで、いいかもって思ってしまう結果かなっと…

 

あと復習のため UpToDateを引用

「化膿性脊椎炎」の該当なく

「骨髄炎」で抽出

 

Vertebral osteomyelitis

 

Most cases of vertebral osteomyelitis respond to antimicrobial therapy. However, surgery is necessary in some patients.

 

We recommend, in stable patients, to hold antibiotics until results of blood cultures and needle aspirate are available (Grade 1C).

 

 When the culture and/or Gram stain of the CT-guided needle biopsy is positive, antibiotic therapy should be guided by the results of susceptibility testing. For most patients, we recommend treatment with parenteral antibiotics (Grade 1B).

 

In patients with negative cultures and Gram stains despite repeat biopsies and in unstable patients, we recommend empiric treatment based on the most likely organisms to cause infection (Grade 1B). An appropriate empiric regimen consists of vancomycin (15 to 20 mg/kg/dose every 8 to 12 hours, not to exceed 2 g per dose) plus one of the following: cefotaxime (2 g intravenously [IV] every six hours), ceftazidime (1 to 2 g IV every eight to 12 hours), ceftriaxone (1 to 2 g IV daily), cefepime (2 g IV every 12 hours), or ciprofloxacin (400 mg IV every 12 hours or 500 to 750 mg orally twice daily).

 

If treatment in patients in whom empiric therapy is initiated does not result in objective clinical improvement in three to four weeks, we typically request a third percutaneous needle biopsy or an open surgical biopsy be performed.

 

We routinely treat for a minimum of six weeks. Longer therapy (12 weeks) may be necessary for patients with advanced disease.

 

Surgery is necessary in a minority of patients with vertebral osteomyelitis. 

 

 

すこし古いですが、NEJM 骨髄炎レビュー

Review article

Lew DP, et al. N Engl J Med. 1997

Osteomyelitis. - PubMed - NCBITREATMENT

Basic Principles

Early antibiotic treatment, before extensive destruction of bone or necrosis, produces the best results and must be administered parenterally for at least four — and usually six — weeks to achieve an acceptable rate of cure. To reduce costs, parenteral administration of antibiotics on an outpatient basis has become widely used. A combined antimicrobial and surgical approach should always be considered. At one end of the spectrum of disease (e.g., acute hematogenous osteomyelitis), surgery is usually unnecessary; at the other end (e.g., a consolidated infected fracture), cure may be achieved with antibiotic treatment provided that the foreign material is eventually removed.

In treating hematogenous osteomyelitis in children, the parenteral administration of antibiotics may be rapidly followed by several weeks of oral therapy, provided that the infecting organism has been identified, clinical signs abate rapidly, and the patient's compliance with therapy is good.Because of the limited bioavailability of high-dose oral beta-lactam antibiotics (cloxacillin and cephalexin) and poor gastrointestinal tolerance, early intravenous–oral switch therapy with these drugs is not used in adults with acute osteomyelitis.

Long-term oral therapy with quinolones (ciprofloxacin and ofloxacin) can suppress the symptoms and signs of chronic, refractory osteomyelitis.Although the efficacy of quinolones in the treatment of osteomyelitis due to Enterobacteriaceae is undisputed, their advantage over conventional therapy for infections due to P. aeruginosa, serratia species, and S. aureus (againstS. aureus, these drugs are given alone or in combination with rifampin) has yet to be shown.Nosocomial infections with methicillin-resistant S. aureus or multidrug-resistant gram-negative rods require prolonged intravenous therapy with glycopeptides or broad-spectrum antibiotics.

The local administration of antibiotics, either by instillation or with gentamicin-impregnated beads, has its advocates. However, the diffusion of antibiotics given in this way is limited in time and area, and the method has not undergone controlled study.

 

なお、JAID/JSC 感染症治療ガイド2014 P157

「骨髄炎全般について原則的には6週間の抗菌薬治療期間が望ましい。」

 JAID/JSC感染症治療ガイド2014

JAID/JSC感染症治療ガイド2014


そして、我らの レジデントのための感染症診療マニュアル 第3版 P856

「基本的には6-8週間(最低4週間)とする。なお、踵骨などの血流の乏しい部位の骨髄炎では、通常より長めに治療しなければならず、必要に応じて12週まで延長する。」

レジデントのための感染症診療マニュアル 第3版

レジデントのための感染症診療マニュアル 第3版