I have blogged a number of times about the questions surrounding some of the unknown, unproven issues surrounding the treatment of osteomyelitis, including the duration of antibiotic therapy and the “need” for surgical debridement. It continues to amaze me how — it does not matter where or to whom I lecture — if I ask the question, “How long do you need to treat osteomyelitis and via what route?” the answer is always the same “four to six weeks of IV therapy.” This comes despite a total lack of human evidence to support that position.
I recently came across an interesting paper, which adds to the ever increasing body of scientific literature that shows this old axiom is just not justified. In the February 2011 online issue of International Orthopedics, Rod-Fleury and colleagues looked at duration of postsurgical antibiotic therapy in adult chronic osteomyelitis (www.ncbi.nlm.nih.gov/pubmed?term=Rod-Fleury%20T  ).1 This is from the same group at Geneva University Hospital that published on the utility of sinus tract cultures on which I commented back in November of this past year (see http://bit.ly/gwmdwM  ).
The authors retrospectively examined 49 episodes of chronic osteomyelitis with a minimum of two years of follow-up.1 I should point out that they specifically excluded diabetic foot osteomyelitis. The patients had a median number of two surgical debridements. These were bad cases with almost all being considered Cierny-Mader IV category disease with the patients having a minimum duration of symptoms of three months. The authors found that 80 percent of patients were in remission at the two-year follow-up point.
It is important to stress the conclusion right from the abstract that, after multivariate logistic regression analysis, “one week of intravenous therapy had the same remission as two to three weeks or ≥ 3 weeks. More than six weeks of total antibiotic treatment equaled ≤ six weeks.”1 To quote the conclusion of the paper, “If our retrospective results are confirmed, a shorter or oral antibiotic treatment post-debridement could further decrease antibiotic consumption, as well as the related costs, adverse effects and selective pressure for resistant bacterial pathogens.”
Now this is far from a perfect study and the authors do a commendable job citing the limitations of the study. Also, they take the almost chauvinistic surgical attitude right in the beginning of the introduction that “Chronic bacterial osteomyelitis is a surgical disease.” This is still not totally proven in my mind but it does again bolster the argument that we need to re-examine this entire four to six week IV dogma.
1. Rod-Fleury T, Dunkel N, Assal M, et al. Duration of post-surgical antibiotic therapy for adult chronic osteomyelitis: a single-centre experience. Int Orthop. 2011 Feb. 12 (Epub ahead of print).
Editor’s note: This blog was originally published at http://www.leinfections.com/antibiotics/more-on-antibiotics-and-osteomye...  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/  .