Prophylactic Antibiotics and Neuraxial

[agolden1]

In fellowship, our institutional dogma was that if a patient was on antibiotics we would not perform any neuraxial intervention.

Have patient on chronic antibiotics (6 months into 2.5 year course) for knee replacement hardware infection with a lumbar radicular symptom who could benefit from a LESI. No infectious symptoms right now.

I spent some time reviewing the literature (google schoalr search) this morning and couldn't find anything that spoke to recommendations if a patient was on chronic antibiotics. A thred on this forum in the past suggested possibly moving forward so long as asymptomatic.

Does anyone have any published studies to back up proceeding or not proceeding, or any thoughts on proceeding in this scenario?

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[callmeanesthesia]

Patient will likely be seeing an ID doc - send them a letter asking whether patient is cleared for spine injection.

 

[Ducttape]

i did not find any good data on this.


the 2 concerns i would have - will you potentially seed the epidural space with the injection, and will your treatment impact their antibiotic treatment.



the former is not really an issue on chronic antibiotics.

i doubt that your small amount of steroids would affect antibiotic efficacy, but, like callmeanesthesia stated, i would let ID know.

 

[Orin]

Safest is to just not do it, but there's no data on this.

If you feel strongly about an epidural, I would proceed with ensuring that they've got the oral antibiotics on board. If you don't feel strongly, I would continue conservative care.

Infectious disease can give you their thoughts, but at this time point they're just trying to suppress things.

You can also get a CRP, ESR, and/or procalcitonin to make sure they're not about to erupt with something due to the antibiotics not working

 

[RoloTomassi]

i did not find any good data on this.


the 2 concerns i would have - will you potentially seed the epidural space with the injection, and will your treatment impact their antibiotic treatment.



the former is not really an issue on chronic antibiotics.

i doubt that your small amount of steroids would affect antibiotic efficacy, but, like callmeanesthesia stated, i would let ID know.

Never understood the seeding theory. If it's in their bloodstream, it's already perfusing into epidural space right? How does poking into a location remote from the infection promote spread?

 

[agolden1]

Thanks everybody. Appreciate the thoughts here.

 

[BobBarker]

Probably not worth it only 6m out.

 

[deleted875186]

Never understood the seeding theory. If it's in their bloodstream, it's already perfusing into epidural space right? How does poking into a location remote from the infection promote spread?

Because your placing a needle in the epidural space and introducing fluid and steroid into the space, increasing likelihood that bacteria can grow there. Also, risk of oozing blood into the space, any collection of blood is an area where bacteria can grow.

 

[MitchLevi]

Probably not that big of an issue TBH.

I understand the concern. Just have them see ID and get clearance.

 

[Ducttape]

Never understood the seeding theory. If it's in their bloodstream, it's already perfusing into epidural space right? How does poking into a location remote from the infection promote spread?

my teaching was that injecting this through possibly contaminated skin and subcutaneous tissue (if septic) could introduce and concentrate the infection in an area with fewer natural defenses, ie macrophages and the like...

 

[bedrock]

Hm. So I have a 40s patient with recurrent olecranon bursitis. On augmentin for three weeks. Cultures are negative, though many neutrophils in the aspirate. Ortho has debated removing the bursa, but still on the fence.

Concurrent lumbar radiculopathy, In pain, wants an ESI soon.

Likely would take over a month to see ID.

Would you guys/gals require ID clearance in this situation or proceed with the lumbar ESI?

 

[RoloTomassi]

Hm. So I have a 40s patient with recurrent olecranon bursitis. On augmentin for three weeks. Cultures are negative, though many neutrophils in the aspirate. Ortho has debated removing the bursa, but still on the fence.

Concurrent lumbar radiculopathy, In pain, wants an ESI soon.

Likely would take over a month to see ID.

Would you guys/gals require ID clearance in this situation or proceed with the lumbar ESI?

Proceed. I don't agree with abx, it's inflammation not infection. Aspirate, inject, avoid pressure usually works for me.

 

[SSdoc33]

id just do the epidural, but mention it when consenting patient

 

[lobelsteve]

Hm. So I have a 40s patient with recurrent olecranon bursitis. On augmentin for three weeks. Cultures are negative, though many neutrophils in the aspirate. Ortho has debated removing the bursa, but still on the fence.

Concurrent lumbar radiculopathy, In pain, wants an ESI soon.

Likely would take over a month to see ID.

Would you guys/gals require ID clearance in this situation or proceed with the lumbar ESI?

24 hr afebrile and on ABX is my criteria for all non CNS infections.

 

[Ducttape]

this is not an active infection.

he has also been on it for 3 weeks.

i would probably do the injection.

 

[Painologist]

Building off of this question. I have a patient on chemotherapy for Leukemia who is on prophylactic Bactrim 3 times/week during treatment. He needs a TFESI for severe lumbar radic. Oncologist recommended an injection. Would you proceed assuming he has no infectious symptoms? White count is slightly elevated secondary to chemo treatment.

 

[au bon pain]

Building off of this question. I have a patient on chemotherapy for Leukemia who is on prophylactic Bactrim 3 times/week during treatment. He needs a TFESI for severe lumbar radic. Oncologist recommended an injection. Would you proceed assuming he has no infectious symptoms? White count is slightly elevated secondary to chemo treatment.

Why ppx with bactrim specifically? Assuming no other major details to this story (ie not profoundly neutropenic), I’d explain higher chance of infection risk from procedure during consent and if pt ok with that, do the shot.

 

[Painologist]

Why ppx with bactrim specifically? Assuming no other major details to this story (ie not profoundly neutropenic), I’d explain higher chance of infection risk from procedure during consent and if pt ok with that, do the shot.

Not sure, will ask the patient. No Neutropenia.

 

[MitchLevi]

No problems. Do the shot.

 

[clubdeac]

Never understood the seeding theory. If it's in their bloodstream, it's already perfusing into epidural space right? How does poking into a location remote from the infection promote spread?

Not sure the exact mechanism but it does. Saw a patient recently who had an ACDF c/b hardware infx. While in the hospital he develops an L5 radic. Surgeon orders an epidural. IR guy does epidural. Few days later symptoms markedly worsen. Finally get new MRI. Shows L5-S1 disciitis and epidural abscess. I would never have done the epidural

 

[RoloTomassi]

Not sure the exact mechanism but it does. Saw a patient recently who had an ACDF c/b hardware infx. While I’m the hospital he develops an L5 radic. Surgeon orders an epidural. IR guy does epidural. Few days later symptoms markedly worsen. Finally get new MRI. Shows disciitis and epidural abscess. I would never have done the epidural

Interesting. And I'm assuming there was an MRI showing that the new radic symptoms were not from an abscess forming?

 

[GorillaPanic]

Not sure, will ask the patient. No Neutropenia.

Is pt on high dose steroids? May be PCP suppression.

 

[MitchLevi]

Not sure the exact mechanism but it does. Saw a patient recently who had an ACDF c/b hardware infx. While I’m the hospital he develops an L5 radic. Surgeon orders an epidural. IR guy does epidural. Few days later symptoms markedly worsen. Finally get new MRI. Shows disciitis and epidural abscess. I would never have done the epidural

Cervical fusion with an infection in the neck, gets an acute L5 radic in the hospital...

He had an infxn which caused the leg pain.

Shouldn't have injected without a new MRI first, which would have showed the abscess and discitis. Shot didn't do that.

Unless I'm misreading the scenario.

 

[clubdeac]

Cervical fusion with an infection in the neck, gets an acute L5 radic in the hospital...

He had an infxn which caused the leg pain.

Shouldn't have injected without a new MRI first, which would have showed the abscess and discitis. Shot didn't do that.

Unless I'm misreading the scenario.

They got an MRI which at that time did not show an infection. That’s not too say an infection may not have been brewing and just wasn’t visible yet on imaging

 

[Ducttape]

was he being treated for an infection prior to the injection?

thats what i see happening the most. patient on triple antibiotics, spiking temps, from sepsis of undetermined location, and they want an epidural, ofttimes "because he was due for one by his outpatient pain doc"