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Reply to Werth et al.

We appreciate the insightful comments made by Werth et al pertaining to the 2015 Infectious Diseases Society of America guidelines on native vertebral osteomyelitis (NVO) published in the September 2015 issue of Clinical Infectious Diseases [1]. The points raised are related to the extended duration of concomitant aminoglycoside therapy and the optimal dose of daptomycin in enterococcal NVO. Enterococcus species comprised 2% of episodes of NVO in a cohort of 260 patients seen at the Mayo Clinic between 1994 and 2006 [2]. The incidence is even lower in other cohorts and community-based series [3, 4]. Therefore, one can imagine that the level of clinical evidence supporting any management strategies pertaining to enterococcal NVO is going to be very low. We agree that in the presence of concomitant infective endocarditis (IE), NVO patients should be managed according to the most recent IE guidelines. Based on the IE guidelines that were subsequently published in October 2015, the use of dual β-lactams (ampicillin and ceftriaxone) as an alternative to penicillin and gentamicin carried a recommendations of class IIa, with level of evidence B [5]. As outlined in Table 2 of the NVO guidelines, other patients with enterococcal NVO (without associated endocarditis) can be managed with penicillin without or with a short course of aminoglycoside therapy [1].The average age of the patients diagnosed with NVO is 59 years of age, rendering the tolerance of aminoglycoside use in this patient papulation less of an issue when compared to IE [2, 3, 4]. The experience on the use of daptomycin in enterococcal IE is stemming from case reports and small case series [5]. The experience in the management of enterococcal NVO is also stemming from few case reports and the collective experience of the panel members. The dose of daptomycin of 10–12 mg/kg mentioned in the letter to the editor is for the rare enterococcal endocarditis cases caused by strains that are resistant to penicillin, aminoglycosides, and vancomycin [5]. In a European retrospective clinical registry study on the use of daptomycin in 220 patients with osteomyelitis, 11 (5%) were due to Enterococcus species and 11% had “back” listed as the site of the infection. In this study, the use of higher dosage of daptomycin was not associated with a better outcome when compared with the standard dose [6], The high protein binding of daptomycin may limit its effectiveness, despite high serum levels. We believe that the use of higher dosage of daptomycin should be reserved to occasional cases of NVO due to vancomycinresistant enterococci in consultation with an infectious diseases clinician and a spine surgeon.