Do antibiotics have a role in treating injured workers with chronic low back pain? Systematic review and meta-analysis.

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Journal Article
Internal Medicine Journal, 2020, 50, (S1), pp. 13-13
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Background: In patients with chronic low back pain (CLBP), Modic‐1 endplate signs on MRI have been linked to chronic infection with bacteria, particularly P. Acnes. In a recent literature review, for biopsied disc material, the pooled estimate for the proportion of positive samples for bacteria was 25%. Two recent trials of antibiotics for CLBP and Modic‐Type‐1‐changes in vertebral endplates adjacent to disc herniation, had controversial and divergent conclusions. Objectives: This is a systematic review and meta‐analysis of randomised placebo‐controlled trials (RCT) to investigate antibiotic treatment for workers with CLBP & Modic‐changes and to generate research hypotheses. Methodology: We performed a database search for RCT for antibiotics and CLBP and applied the Risk‐of‐Bias‐2 protocol. We extracted outcomes and adverse events then performed random effects meta‐analysis. A minimum important change on Roland Morris Disability Questionnaire (RMDQ) of 5 points was pre‐specified. Results: Three trials were included that investigated oral amoxicillin, or amoxicillin with clavulanate. Each trial reported a statistically significant benefit of antibiotics. Meta‐analysis resulted in an estimated distribution for means that had an overall mean of ‐4.2 (95% CI: ‐6.6 to‐1.6) points on the RMDQ scale. There was high risk of bias in two studies. There was heterogeneity in the proportion of patients with recent surgery, and baseline disability. Conclusion: The overall estimated benefit of antibiotics for CLBP and Modic‐1 changes was statistically significant but had borderline clinical effect. In the small proportion of patients expected to have chronic infection there is probably an important benefit. Further research should focus on clinical investigations for patient selection.
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