# 300. Clinical Manifestations and Risk Factors for Treatment Failure in Native Vertebral Osteomyelitis: A 25-Year Multicenter Mayo Clinic Experience

## TL;DR

This 25-year study identifies risk factors for treatment failure in spinal infections, showing that diabetes, multi-level involvement, and MRSA increase failure risks.

## Contribution

The study provides long-term insights into treatment failure risk factors in native vertebral osteomyelitis using a large multicenter cohort.

## Key findings

- Treatment failure occurred in 11% of patients within 6 months and 14% at 5 years.
- Diabetes, multilevel vertebral involvement, and MRSA infection were independent predictors of treatment failure.
- Mortality rates were 12% at 6 months and 33% at 5 years.

## Abstract

Native vertebral osteomyelitis (NVO) is a life-threatening spinal infection with considerable clinical burden. Although increasing literature has described its features and associated treatment failure, large-scale cohorts with long-term follow-up remain limited. Herein, we evaluated a large cohort of patients with NVO to characterize the clinical manifestations, management, and long-term outcomes, and to further explore factors associated with treatment failure.Table 1.Baseline characteristics of patients with native vertebral osteomyelitisTable 2.Treatment, failure rates, and mortality in patients with native vertebral osteomyelitis

Baseline characteristics of patients with native vertebral osteomyelitis

Treatment, failure rates, and mortality in patients with native vertebral osteomyelitis

We conducted a retrospective multicenter cohort study of adults (≥18 years) with NVO across Mayo Clinic sites between 1999 and 2024. Data on demographics, clinical manifestations, antimicrobial therapy, and surgical intervention were collected. Cumulative incidence of treatment failure was estimated as a function of follow-up accounting for the competing risk of death. Independent predictors of treatment failure were evaluated in a multivariable Cox regression model with time-dependent covariates.Table 3.Multivariable predictors of treatment failure in patients with native vertebral osteomyelitisFigure 1.Cumulative incidence of death and treatment failure following diagnosis of native vertebral osteomyelitis(A) Short-term (12-month) cumulative incidence of death and treatment failure (magnified view of the first year from panel B).(B) Long-term (up to 7 years) cumulative incidence of death (dotted orange line) and treatment failure (solid blue line).

Multivariable predictors of treatment failure in patients with native vertebral osteomyelitis

Cumulative incidence of death and treatment failure following diagnosis of native vertebral osteomyelitis

(A) Short-term (12-month) cumulative incidence of death and treatment failure (magnified view of the first year from panel B).

(B) Long-term (up to 7 years) cumulative incidence of death (dotted orange line) and treatment failure (solid blue line).

Among 1,255 patients included (median age 67 years; 66% male), lumbosacral involvement was most common (65%), with multilevel vertebral involvement ( >2 levels) in 21%. Epidural abscesses were present in 43%, paravertebral abscesses in 42%, and psoas abscesses in 20%. Pathogens were identified in 77%, most commonly S. aureus (50%; MSSA 37%, MRSA 13%), followed by Streptococcus species (22%), and Gram-negative bacilli (11%) (Table 1). The median total antibiotic duration was 59 days (IQR, 42–132). Surgical intervention was performed in 13% after a median of 2 days (IQR, 1-5). Treatment failure occurred in 162 patients during a median follow-up of 2.8 years (6-month and 5-year cumulative incidence were 11% and 14%, respectively), with the median time to failure of 3.1 months. Cumulative mortality was 12% at 6 months and 33% at 5 years (Table 2, Figure 1). Diabetes (HR 1.90, 95% CI 1.16–3.12), multilevel vertebral involvement (HR 1.75, 95% CI 1.22–2.51), and MRSA infection (HR 2.11, 95% CI 1.06–4.18) were independently associated with increased risk of treatment failure (Table 3).

This 25-year study highlights the persistent burden of treatment failure in NVO and associated risk factors, underscoring the importance of early recognition of high-risk features to optimize outcomes.

All Authors: No reported disclosures