A New Review Of Antibiotic Therapy For Osteomyelitis

Warren S. Joseph DPM FIDSA

I wish all of my readers a healthy, happy and prosperous 2012. With this post, I am trying something a bit different. In the past, I usually waited to put up a post until I come up with an “aha” moment on something I have seen, heard or read about, and then pontificate on this site. These moments could occur only days apart but usually it was a much longer time period leading to relatively infrequent additions to the blog.

My “resolution” for 2012 is to try to put up more frequent, quick hits in which I don’t have as much to write and you don’t have as much to read. That’s not to say that I won’t still post the occasional tome on a particular topic. Sometimes, I just have to vent.

A recent paper titled “Systemic Antibiotic Therapy for Chronic Osteomyelitis in Adults” has been published online in Clinical Infectious Diseases by Brad Spellberg, MD, at UCLA and Ben Lipsky, MD, at the Puget Sound VA.1 I consider it a must read for followers of this site.

This excellent review covers topics including: the pharmacology of osteomyelitis therapy (i.e. parenteral versus oral, bone penetration); animal models of osteomyelitis; human non-randomized clinical trials; and randomized clinical trials. It is thorough yet quite readable at only 11 pages (there are, however, 172 references) with five tables outlining all of the studies discussed.

The authors arrive at four conclusions, which I quote directly from the paper:

1. “Oral antibiotic therapy with highly bioavailable agents is an acceptable alternative to parenteral therapy.”

2. “Adding rifampin to a variety of antibiotic regimens has been shown to improve cure rates.”

3. “Clinicians must individualize the duration of antibiotic therapy based on the patient’s clinical and radiographic response …”

4. “Surgical resection of necrotic and infected bone, in conjunction with antibiotic therapy, appears to increase the cure rate of chronic osteomyelitis. However, not all cases of chronic osteomyelitis require surgical debridement for cure, and we need studies to clarify which may and which may not.”

None of these conclusions should come as a surprise to regular readers of this blog or those who have heard me lecture on the topic as I have discussed these very points in the past. Dr. Lipsky and I collaborate frequently, and I find it almost frightening how often we agree. In this one paper, he and Dr. Spellberg have eloquently laid out all of the evidence supporting these positions. If I have said it once, I have said it a thousand times: We must rethink the universally pervasive dogma of four to six weeks of IV antibiotic therapy for osteomyelitis based on the best available evidence.

Editor’s note: This blog was originally published at http://www.leinfections.com/antibiotics/a-new-review-of-antibiotic-thera... and has been adapted with permission from Warren Joseph, DPM, FIDSA, and Data Trace Publishing Company. For more information about the Handbook of Lower Extremity Infections, visit www.leinfections.com/ .


1. Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis. 2011 Dec. 12 (Epub ahead of print).

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