An Evidence-Based Approach to Treating Osteomyelitis

Abstract

Infections of the foot involving underlying bone can be difficult to accurately diagnose and effectively treat and are associated with a high rate of amputations and other treatment-related complications. Successful treatment of diabetic foot osteomyelitis (DFO) requires accurately detecting bone involvement (optimally by sampling bone for culture and histopathology), determining the likely causative pathogen(s), considering the need for any surgical resection, and selecting appropriate antibiotic therapy. The most common causative pathogen in DFO is Staphylococcus aureus, but other microorganisms, often in mixed infection, are frequently isolated. Major amputations were once commonly performed for DFO but, with improved diagnostic and surgical techniques, “conservative” surgery (limiting resection to infected and necrotic bone) is becoming routine, especially for forefoot infections. More recently, studies have demonstrated that selected cases of DFO can even be treated without surgical resection, using antibiotic therapy alone. Antibiotic therapy has traditionally been initiated by the parenteral route, but recent studies, using treatment with highly bioavailable oral antibiotic agents, have demonstrated the effectiveness of shorter durations of (or even no) parenteral therapy. The usual duration of antibiotic therapy ranges from as little as a few days if all infected bone has been resected, to up to 6 weeks if infected bone remains. The specific antibiotic regimen should be based on the results of culture and sensitivity testing, as most commonly used agents can achieve adequate bone levels. Apparently successful treatment should be considered a remission until it has been sustained for at least a year.