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OBJECTIVE: The incidence of spondylodiscitis is rising across Europe, but the ideal treatment approach remains controversial. The choice between conservative and surgical therapies is ambiguous due to a lack of consensus. This European survey aimed to explore prevailing treatment paradigms for primary spondylodiscitis. METHODS: Spine neurosurgeons were invited through the European Association of Neurosurgical Societies Spine Section's mailing list to participate in an online survey featuring 7 spondylodiscitis case vignettes. Along with general management queries, specific patient treatment questions were posed. Data analysis was performed using R software (version 4.0.4). The index of qualitative variation (IQV) was calculated to quantify the variability in responses. RESULTS: A total of 130 responses were collected, comprising 86.9% board-certified neurosurgeons and 13.1% neurosurgeons in training, with an average of 11 years of practice. Most respondents performed 50-100 spine surgeries annually, with 66.7% specializing in spine surgery. An epidural empyema causing pronounced neurological deficits influenced 95.4% toward a surgical intervention, and mild neurological deficits and challenges in pathogen identification prompted 72.3% and 80%, respectively, to consider a surgical approach. Vertebral body destruction and spinal deformity directed 60% and 66.2%, respectively, toward surgery, whereas advanced age and comorbidities had a much smaller impact-5.4% and 9.2%, respectively. Clinical vignettes highlighted a predominant preference for conservative treatment in specific cases, with statistical significance (p < 0.05). The IQV values evaluated for each question ranged from 0.88 to 0.99, indicating low agreement across all questions among respondents. When examining the average IQV by country, intercountry variations in IQV were substantial, as illustrated by the diverse range of overall mean IQV values (0.15-0.85). CONCLUSIONS: The findings reveal a significant variability in the treatment of spondylodiscitis among European neurosurgeons, with most neurosurgeons opting for conservative treatment. These diverse strategies, both between and within countries, highlight an imperative for evidence-backed guidelines and consensus statements for this grave condition.

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Retrospective cohort study. To assess the utility of the LACE index for predicting death and readmission in patients with spinal infections (SI). SIs are severe conditions, and their incidence has increased in recent years. The LACE (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) index quantifies the risk of mortality or unplanned readmission. It has not yet been validated for SIs. LACE indices were calculated for all adult patients who underwent surgery for spinal infection between 2012 and 2021. Data were collected from a single academic teaching hospital. Outcome measures included the LACE index, mortality, and readmission rate within 30 and 90 days. In total, 164 patients were analyzed. Mean age was 64.6 (± 15.1) years, 73 (45%) were female. Ten (6.1%) patients died within 30 days and 16 (9.8%) died within 90 days after discharge. Mean LACE indices were 13.4 (± 3.6) and 13.8 (± 3.0) for the deceased patients, compared to 11.0 (± 2.8) and 10.8 (± 2.8) for surviving patients (p = 0.01, p < 0.001), respectively. Thirty-seven (22.6%) patients were readmitted ≤ 30 days and 48 (29.3%) were readmitted ≤ 90 days. Readmitted patients had a significantly higher mean LACE index compared to non-readmitted patients (12.9 ± 2.1 vs. 10.6 ± 2.9, < 0.001 and 12.8 ± 2.3 vs. 10.4 ± 2.8, p < 0.001, respectively). ROC analysis for either death or readmission within 30 days estimated a cut-off LACE index of 12.0 points (area under the curve [AUC] 95% CI, 0.757 [0.681-0.833]) with a sensitivity of 70% and specificity of 69%. Patients with SI had high LACE indices that were associated with high mortality and readmission rates. The LACE index can be applied to this patient population to predict the risk of early death or unplanned readmission.

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BACKGROUND CONTEXT: Pyogenic spinal infections (PSIs) are severe conditions with high morbidity and mortality. If medical treatment fails, patients may require surgery, but there is no consensus regarding the definition of medical treatment failure. PURPOSE: To determine criteria for defining failure of medical treatment in PSI through an international consensus of experts. STUDY DESIGN: A two-round basic Delphi method study. SAMPLE: One hundred and fifty experts from 22 countries (authors or co-authors of clinical guidelines or indexed publications on the topic) were invited to participate; 33 answered both rounds defining the criteria. OUTCOME MEASURES: A scale of 1 to 9 (1: no relevance; 9: highly relevant) applied to each criterion. METHODS: We created an online survey with 10 criteria reported in the literature to define the failure of medical treatment in PSIs. We sent this survey via email to the experts. Agreement among the participants on relevant criteria (score ≥7) was determined. One month later, the second round of evaluations was sent. An extra criterion suggested by six responders in the first round was incorporated. The final version was reached with the criteria considered relevant and with high agreement. RESULTS: The consensus definition is: (1) There is an uncontrolled sepsis despite broad spectrum antibiotic treatment, and (2) There is an infection relapse, following a six-week period of antibiotics with clinical and laboratory improvement. CONCLUSIONS: Our definition of failure following nonsurgical treatment of PSI can offer a standardized approach to guide clinical decision-making. Furthermore, it has the potential to enhance scientific reporting within this field.

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Objective: The purpose of this study is to investigate the efficacy of the GAID-Protocol, a bundle of intra- and postoperative infection prevention measures, to reduce implant-associated infections in patients undergoing posterior spinal fusion with instrumentation. These preventive measures are organized into a protocol that includes recommendations for four critical areas of implant protection (acronym GAID): Gloves, Antiseptics: sodium hypochlorite/hypochlorous acid (NaOCl/HOCl), Implants and Drainage-use in large wounds. Methods: We performed a single-site retrospective review of cases undergoing posterior spinal fusion with instrumentation for primarily degenerative spinal diseases before and after implementation of the GAID-Protocol that was specifically designed to protect against implant-associated infections. The primary outcome was postoperative wound complications requiring surgical intervention, with a particular focus on infectious spondylitis/discitis. Results: 230 cases were included: 92 (Group A) before and 138 (Group B) after protocol implementation. Overall, wound complications requiring surgical intervention occurred in 7.6% patients in Group A and in 3.6% patients in Group B (p = 0.2297). Of these, infectious spondylitis/discitis was present in 5.4% in Group A and in none of Group B (p = 0.0096). The ratio of infectious spondylitis/discitis to other wound problems was 71% to 29% in Group A, while it was 0% to 100% in Group B (p = 0.0278). The mean time interval between the first revision surgery for wound complications and hospital discharge was significantly different, 38 days SD 20.3 in Group A and 14.4 days SD 8.6 in Group B (p = 0.0442). Conclusions: In our study, adherence to the GAID-Protocol resulted in a shift from severe to significantly less severe and easier to treat wound complications. Adoption of the GAID-Protocol might contribute to the reduction of implant-associated infections.

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Spinal epidural abscess (SEA) is a rarest form of spinal infections and is characterized by the presence of pus in the space between the dura mater, and the osseoligamentous confines of the vertebral canal. This can cause spinal injury due to direct compression or local ischemia. The major etiology of SEA is bacterial and tuberculous in endemic regions. The incidence of fungal spinal abscess is relatively low and <5% of SEA is attributable to fungi. We, here, report a case of 77-year-old known patient of chronic renal disease on hemodialysis that presented with low-back pain for 15 days and was subsequently diagnosed with SEA by magnetic resonance imaging, and causative organism was identified as Candida by culture. The abscess was surgically drained after laminectomy. The patient improved with surgery and antifungal treatment.

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Treatment of spinal brucellosis with bilateral psoas abscess is a challenging clinical endeavor. We retrospectively evaluated a case of lumbar infection and bilateral psoas abscess, and was effectively managed through a unilateral extreme lateral approach with the aid of NPWT for bilateral drainage. We hypothesize that NPWT can influence the Piezo1 receptor of neutrophils and further influence the interaction between neutrophils and endothelial cells to promote the clearance of infected lesions, and this phenomenon is also observed in pathological slides. This proves that NPWT can rapidly enhance the recruitment of neutrophils in the infected area and improve the local immune response, and after a year of reassessment and tracking, Bilateral drainage using NPWT via a unilateral Extreme Lateral Approach could acquire satisfactory surgical outcomes, can be used as a treatment modality for lumbar infection with bilateral psoas abscesses.

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BACKGROUND CONTEXT: The precise diagnosis and treatment of spinal infections (SI) remains challenging for spine surgeons. Identifying the pathogens of SI through metagenomic next-generation sequencing (mNGS) may be a key approach to addressing this challenge. PURPOSE: To evaluate the accuracy and applicability of mNGS in determining the etiology of SI. STUDY DESIGN: Diagnostic test study. PATIENT SAMPLE: Twenty-five patients who had a clinical suspicion of SI and underwent mNGS testing. OUTCOME MEASURES: The specificity, sensitivity, and time cost of mNGS and bacterial culture were compared. Clinical outcomes were assessed using the numeric rating scale (NRS) score, Oswestry Disability Index (ODI), and the Japanese Orthopedic Association (JOA) score. Demographic data and laboratory results (blood cell count (WBC), erythrocyte sedimentation rate (ESR), neutrophil percentage (NEUT%), and C-reactive protein level (CRP) were also evaluated. METHODS: In this retrospective study, samples were obtained from 25 eligible patients via surgery or CT-guided puncture and subjected to histopathological examination, bacterial culture, and mNGS. The sensitivity and specificity of the bacterial cultures and mNGS were calculated with respect to the histopathological results as a reference. Postoperative antibiotics or antituberculosis drugs were administered on the basis of mNGS results, combined with clinical manifestations, imaging examination, and histopathology. The changes of clinical outcomes and laboratory results after treatment were observed. RESULTS: Of the 25 patients, 21 had a positive pathology, of which 10 showed a tuberculous pathology, and the remaining 11 showed a nontuberculous inflammatory pathology. The sensitivity of mNGS was higher than that of the bacterial culture. However, the difference in specificity between bacterial culture and mNGS was not significant. Moreover, the time needed to perform mNGS was significantly lower than that of bacterial culture and pathology. All patients were followed up for more than three months, and CRP and NEUT% significantly decreased by three months after treatment. There was no significant difference in WBC and ESR. The ODI, NRS and JOA scores were significantly improved after treatment. CONCLUSION: Metagenomic next-generation sequencing technology can play an important role in the detection of pathogens in SI and should be further investigated and applied in future studies.

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AIMS: Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford. METHODS: An observational study was conducted, using data from the Bradford Teaching Hospitals TB database of patients with a formal diagnosis of MSK TB between January 2005 and July 2017. Patient data included demographic data (including nationality/date of entry to the UK), disease focus, microbiology, and management strategies. Disease incidence was calculated using population data from the Office for National Statistics. Poisson confidence intervals were calculated to demonstrate the extent of statistical error. Disease incidence and nationality were also analyzed, and correlation sought, using the chi-squared test. RESULTS: Between January 2005 and July 2017, 109 cases of MSK TB were diagnosed in Bradford. Mean incidence was 1.65 per 100,000 population, per calendar year (SD 0.75). A total of 38 cases required surgical intervention. Low rates of antimicrobial resistance were encountered. A low rate of loss to follow-up was observed (four patients; 3.7%). Overall, 94.5% of patients (n = 103) were successfully treated. 67% of patients (n = 73) reported their country of origin as either India, Pakistan, or Bangladesh. These ethnicities account for around 25% of the local population. CONCLUSION: Bradford maintains a high prevalence of MSK TB infection relative to national data; the prevalence within the local immigrant population remains grossly disproportionate. Typical associated factors (HIV/hepatitis coinfection, drug resistance), have only modest prevalence in our dataset. However, local socioeconomic factors such as deprivation and poverty appear germane as suggested by global literature. We advocate a high degree of suspicion in treatment of atypical infection in any area with similar population factors to ensure timely diagnosis. Cite this article: Bone Jt Open 2022;3(5):432-440.

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Nowadays, Kingella kingae is considered an important cause of primary spinal infections in children aged between 6 and 48 months. The presentation of the disease is often characterized by mild clinical features and a moderate biological inflammatory response, requiring a high index of suspicion. Performing magnetic resonance imaging (MRI) and obtaining an oropharyngeal specimen and subjecting it to a K. kingae-specific nucleic acid amplification test are recommended for its diagnosis. Most patients respond promptly to conservative treatment after administration of antibiotic therapy, which is prolonged for up to 3 months according to the individual clinical and biological response. Invasive surgical procedures are not required except for children who do not improve with antibiotic treatment, develop signs of cord compression, or if the presence of atypical microorganisms is suspected. Kingella kingae spinal infections usually run an indolent and benign clinical course, living no permanent sequelae.

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Spinal discitis (SD) is a rare condition, particularly in the pediatric population. The course of SD may be acute or chronic, and the non-specificity of symptoms leads to great delays in diagnosis. The most commonly isolated causative organism is Staphylococcus aureus whereas gram-negative infections are hardly ever reported in the literature. Comorbidities that increase the risk of bacteremia such as diabetes, chronic kidney disease, HIV, and cancer are major risk factors for SD. Hereby, we present an atypical case of SD in a previously healthy 15-year-old male with an unusual organism, Klebsiella aerogenes, diagnosed by plasma microbial cell-free DNA with negative blood cultures. The clinical course was complicated by antibiotic resistance and subsequent development of a ventral epidural abscess requiring readmission followed by surgical drainage of the abscess with a prolonged course of antibiotics.

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PURPOSE: Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification. METHODS: Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (wκ) to establish the inter- and intra-observer agreement. RESULTS: The inter-observer agreement was substantial considering the main categories (wκ = 0.77; 0.71-0.82), but moderate considering the subtypes (wκ = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (wκ = 0.65; 0.59-0.71), and moderate considering the subtypes (wκ = 0.58; 0.54-0.63). CONCLUSION: The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate.

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Medical treatment with antibiotic therapy remains the mainstay of treatment for pyogenic spondylodiscitis (PS). Nevertheless, orthopaedic treatment is also very important in relieving pain, preventing neurological damage, and avoiding development of spinal deformities (e.g., scoliosis, kyphosis) due to spinal instability. Rigid thoracolumbosacral orthosis (TLSO) bracing is often needed in patients with PS, and average duration of treatment of 3 to 4 months. However, TLSO bracing can be poorly tolerated and limit ability of the patient to go back to a normal life. In 2004 our group developed an alternative surgical treatment to TLSO bracing by percutaneous posterior screw-rod bridge instrumentation of the infected level. This treatment allows early and free mobilization of the patients and is associated with faster recovery, lower pain scores and improved quality of life as previously reported. Herein, we report the clinical outcome of the first 3 patients who have completed the 10 years follow-up mark after the procedure. A case report is also described and details of the procedure are provided.

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BACKGROUND: The literature is lacking on the incidence and management of pyogenic spondylodiscitis (PS) following routine elective surgical procedures. This study aimed to analyze the presentation and treatment outcome in patients with PS following nonspinal surgeries at a tertiary care center with a minimum follow-up of 12 months. METHODS: The demographic, clinical-radiologic features, and treatment outcomes in 40 patients with a diagnosis of PS following nonspinal surgical procedures were retrospectively reviewed and analyzed. RESULTS: The mean age at presentation was 36.4 ± 11.8 years, with 80% of patients being female. The common surgical procedures associated with PS were cesarean delivery (30%), gastric sleeve surgery (12.5%), and dilatation and curettage (12.5%). The tissue biopsy culture was positive in 82.5% of patients. A total of 26 patients (65%) were treated with conservative management and 14 patients (35%) were treated surgically. The mean pretreatment Core Outcome Measure Index score significantly decreased at 12 months (P < .0001) after treatment. The mean pretreatment erythrocyte sedimentation rate (P < .0001) and C-reactive protein (P < .0001) levels significantly decreased at 12 months after treatment. CONCLUSIONS: With most patients with PS following nonspinal surgeries treated with conservative management, excellent clinical outcomes were achieved in all patients at 12 months after treatment. The diagnosis of PS should be considered in patients presenting with low back pain (LBP) with a recent history of undergoing a nonspinal surgical procedure. Patients who undergo surgical procedures are an important "at-risk" patient population, and early diagnosis and treatment can help achieve excellent clinical outcomes. Further studies are required to determine risk factors and possible perioperative precautions that can be taken to prevent PS in patients who undergo nonspine surgeries. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Pyogenic spondylodiscitis should be suspected in patients presenting with LBP after a recent non-spinal surgical procedure. Early diagnosis and treatment can help achieve excellent clinical outcomes in these patients.

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STUDY DESIGN: Retrospective analysis of a single institution prospective, longitudinal database of spinal pyogenic infections. Diagnosis of pyogenic spondylodiscitis (PS) can be challenging. Although presenting symptoms are often non-specific, acute non-remitting axial back pain is the most striking feature. Nevertheless, several authors have reported on the uncommon occurrence of patients with PS without axial back pain. The aim of this study was to characterize presenting symptoms, causative agents, comorbidities, and treatment outcomes of patients presenting with painless pyogenic spondylodiscitis. A total of 214 patients diagnosed with PS were reviewed; patients were divided into two groups: patients presenting with no axial back pain (no pain group, n = 16), and patients presenting with axial back pain (control group, n = 198). Analyzed data comprised general demographics, presenting symptoms, comorbidities, spinal infection location, and amount of spinal involvement. While average age (62.4 vs. 65.0) and sex distribution was similar between the two groups, a significant diagnostic delay was noted in the control group (53 vs. 17 days, p < 0.001). Patients in the no pain group were more likely IV drug abusers or have had liver failure/cirrhosis. Anatomic distribution (i.e., cervical vs thoracolumbar) of the infection did not differ between the two groups, but a higher number of post-surgical infections was noted in the no pain group (37.5 vs. 15.6%, p = 0.026). E. coli and Pseudomonas spp. were more commonly seen in no pain group patients, and mortality was also higher in this group (12.5 vs. 6.0%, p = 0.004).

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BACKGROUND: One percent to 8% of patients undergoing spinal instrumentation surgeries develop infections. There is no consensus on the medical and surgical management of these infections. METHODS: We conducted a retrospective chart review based on International Classification of Diseases, Ninth Revision, and Common Procedural Terminology codes relevant to spinal infections with hardware within Emory Healthcare over a 10-year period. Extracted data included patient demographics, clinical presentation, laboratory and microbiologic results, and surgical and medical management including choice and duration of suppressive therapy. Multivariable logistic regression was used to assess the association of length of use of suppressive antibiotics with treatment success and to identify predictors of use of suppressive antibiotics. RESULTS: Of 869 records, 124 met inclusion criteria. Fifty patients (40.3%) had an infection that occurred after hardware placement, mostly within 3 months postsurgery, while the remainder had vertebral osteomyelitis that required hardware placement. After initial intravenous antibiotic treatment for ≥4 weeks, 72 patients (64.5%) were given suppressive antibiotics. The overall treatment success rate was 78.2%. In spinal infections involving hardware with gram-negative rods, patients were less likely to receive suppressive antibiotics, less likely to have hardware removed, and less likely to have treatment success compared with patients with infections with Staphylococcus species. CONCLUSIONS: Management of spinal infections involving hardware should be tailored to the timing of onset of infection and causative organism. Further studies are needed to determine best management practices, particularly for gram-negative rod infections where the role of further suppressive antibiotics and hardware removal may be warranted.

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Drug reaction, eosinophilia, and systemic symptoms (DRESS) syndrome is a delayed severe drug hypersensitivity (type IVb) syndrome with cutaneous eruption, hematological abnormalities, and multi-organ involvement. The wide spectrum of the disease manifestations, long-term sequelae, and high mortality rates are a clinical concern. Though not commonly reported in spinal surgery patients, the use of long-term antibiotics is a potential causative agent in spinal infections. DRESS syndrome can mimic systemic spinal infections, and clinical diagnosis requires high awareness and extreme vigilance. Prompt recognition and appropriate action can mitigate the potential poor outcomes and improve patient prognosis.

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INTRODUCTION: Management of pyogenic spinal infections (PSI) after the development of neurological deficit has not been specifically addressed in the literature. We aimed to describe real-life clinical outcomes of PSI in patients admitted to an intensive care unit with neurological deficit and identify factors associated with good prognosis. METHODOLOGY: Consecutive patients admitted to ICU with a possible diagnosis of spinal infection over five years' period were included. Descriptive statistics were performed to examine the demographics and clinical parameters. RESULTS: The majority (71%) of patients were male. The mean age was 57.4 years (27-79), and 71% were > 50 years old. At least one underlying risk factor was identified in 68% of the patients; the most common comorbidity was diabetes mellitus (DM). All patients have presented with fever accompanied by a neurological deficit (86%) and back pain (79%). A complete recovery was achieved in 25% of patients. However, the majority of patients had adverse outcomes with 21.4% mortality, and 43% remaining neurological sequelae. Increased age with a cut-off of 65 years and pre-existing DM were identified as being associated with poor outcome. CONCLUSION: Mortality among patients admitted to ICU with PSI was significantly higher than reported in the literature. The residual neurological deficit was common, one-third of patients had remaining neurological sequelae, and only one-fourth had complete recovery. Increased age and background DM were the most important determinants of poor clinical outcome. The impact of DM appears to be much more important than currently recognised in this population.

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Despite recent improvements in surgical and antimicrobial therapies, few generally applicable guidelines exist for spondylodiscitis management. We reviewed a consecutive series of patients as well as the past 18 years of the literature and analyzed outcomes for either conservative or surgical treatment. We analyzed a consecutive series of adults with spontaneous spondylodiscitis treated at our institution over the last 6 years. We analyzed predictors for neurological deficits, vertebral collapse, and surgical treatment. We also performed a meta-analysis of the literature between 2000 and 2018, stratifying the results between surgical and conservative treatment outcomes. A younger age at diagnosis, cervical location, tubercular infection, coexistence of morbidities, and vertebral collapse were predictors of surgical intervention. Cervical spondylodiscitis, vertebral collapse, and epidural collection were associated with a higher risk of developing neurological deficits, while tubercular spondylodiscitis was associated with a higher risk of vertebral collapse. Based on the current literature, conservative treatment has success rates similar to those of surgical treatment but lower complication and mortality rates. In cases without an absolute indication for surgery, a conservative approach should be considered as the first-line treatment. A closer diagnostic and clinical follow-up should be recommended in patients with cervical tract or tubercular spondylodiscitis because of the higher risk of developing bone collapse and neurological deficits.

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BACKGROUND: Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management. METHODS: A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus. RESULTS: Literature reveals that on the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of physical, radiological, and microbiological examinations. Microbiological culture samples can be obtained by a percutaneous computed tomography-guided procedure or by an open surgical biopsy. When possible, the samples should be harvested before antibiotic treatment is started. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and failure of conservative treatment. CONCLUSION: A multidisciplinary approach involving both a spinal surgeon and an infectious disease specialist is necessary to better define the treatment strategy. Based on literature findings, a treatment algorithm for the diagnosis and management of primary spinal infections is proposed.

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Spinal epidural abscess (SEA) due to Streptococcus pneumoniae is a rare entity, but it is associated with high mortality. Here, we describe a rare case of pneumococcal SEA in an immunocompetent adult who presented with fever, lower back pain and paresis. Central nervous system examination revealed a decreased power in bilateral lower limbs. Magnetic resonance imaging of the lumbosacral spine showed loculated pus collection in the epidural space at the level of L4-L5 vertebrae. Pus obtained following L4-L5 decompression along with blood cultures grew S. pneumoniae. The patient was treated with clindamycin and cefoperazone-sulbactam for 6 weeks, and no relapse was noted on 11 months follow-up.

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