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The Best Way to Treat Osteomyelitis

Are antibiotics or conservative surgery better for treating diabetic foot osteomyelitis?… 

The term "osteomyelitis" was first coined in 1844; until the invention of penicillin, the primary cure for osteomyelitis was amputation. Osteomyelitis is defined as an infection of the bone; 34% of patients who get osteomyelitis have significant peripheral vascular disease. In diabetic populations, a foot infection or foot ulcers may further lead to the spread of the infection to neighboring tissues and bones. Bone biopsies and other cultures are often taken to confirm the present species; staphylococcus aureus is the most common organism found. Treatment generally involves IV antibiotics for 4-6 weeks along with mild surgical debridement. Amputation is usually the last line of defense unless the patient presents with severe necrotic bone. Previous studies do not provide much information about which patients require surgery versus those needing antibiotic treatment.

In this study, the researchers compared the outcomes of the treatment of diabetic foot osteomyelitis in patients treated exclusively with antibiotics versus patient who underwent conservative surgery, following up the patients for a period of 12 weeks after healing. The initial medical treatment was compared to the surgical treatment of diabetic foot osteomyelitis.

Between January 1, 2010, and December 31, 2012, a prospective randomized comparative trial of patients with diabetes who had received a diagnosis of neuropathic foot ulcers complicated by osteomyelitis was carried out at the Diabetic Foot Unit at the Complutense University of Madrid. Patients were randomized into the following two groups: the antibiotics group (AG) and the surgical group (SG). Antibiotics were given for a period of 90 days in the AG. Patients in the SG received conservative surgery with postoperative antibiotic treatment for 10 days.

Eighteen patients (75%) achieve primary healing in the AG, and 19 (86.3%) in the SG (P=0.33). The median time to healing was 7 weeks (quartile [Q] 1 to Q5, Q3-Q8) in the AG and 6 weeks (Q1-Q3, Q3-Q9) in the SG (P=0.72). The conditions of four patients from the AG worsened (16.6%) and they underwent surgery. Three patients from the SG required reoperation. No difference was found between the two groups regarding minor amputation (P=.336).

The study was conducted at a single-site with one highly trained surgeon who performed all of the surgeries in this study. The primary outcome was the rate and time until healing of the ulcer or operative wound in those undergoing surgery. All patients taking antibiotics were asked to stop taking the antibiotics two weeks prior to this study. In each outcome the surgery patients did better than the subjects in the antibiotic group: 75% of the subjects in the antibiotic group had a notable rate of healing versus 86.3% of the subjects in the surgery group. However, the study concluded that the results were not clinically significant and that further investigation is needed.

In conclusion, this study suggested that surgery was not clinically better than antibiotic use in diabetic foot ulcer patients but further research is needed to accurately compare the two treatment options.

Diabetes Care 2014;37:789-795 DOI: 10.2337/dc13-1526

 

Lipsky, Benjamin. Treating Diabetic Foot Osteomyelitis Primarily with Surgery or Antibiotics: Have we answered the question? Diabetes Care. 2014;37:593-595.