Oral Antibiotic Management of Acute Osteomyelitis of the Hand: Outcomes and Cost Comparison to Standard Intravenous Regimen

Abstract

Background: Acute, direct inoculation osteomyelitis of the hand has traditionally been managed by intravenous antibiotics. With proven high levels of bone and joint penetration, specific oral antimicrobials may deliver clinical efficacy but at substantially lower cost. Methods: Sixty-nine adult patients with surgically proven acute, direct inoculation osteomyelitis of the hand were evaluated for clinical response on a 6-week postdebridement regimen of susceptibility-matched oral antibiotics. Inclusion required gross purulence and bone loss demonstrated at the initial debridement and radiographic evidence of bone loss. Excluded were 2 patients with extreme medical comorbidities. There were 53 men and 16 women with a mean age of 46 years. Mean follow-up was 16 weeks (±10). The cost model for the outpatient oral antibiotic treatment was intentionally maximized using Walgreen’s undiscounted cash price. The cost model for the traditional intravenous treatment regimen was intentionally minimized using the fully discounted Medicare fee schedule. Results: All patients achieved resolution of osteomyelitis by clinical and radiographic criteria. In addition, 7 patients underwent successful subsequent osteosynthesis procedures at the previously affected site without reactivation. The mean postdebridement direct cost of care per patient in the study cohort was $482.85, the cost of the antibiotic alone. The postdebridement direct cost of care per patient on a regimen of vancomycin 1.5 g every 12 hours via peripherally inserted central catheter line was $21 646.90. Conclusions: Acute, direct inoculation osteomyelitis of the hand can be successfully managed on oral antibiotic agents with substantial direct and indirect cost savings.

Peripherally Inserted Central Line Catheters following Hand and Wrist Infections

“…Several studies have shown the effectiveness of oral antimicrobial therapy for superficial and deep infections of the hand and wrist. [13][14][15] However, it is important to recognize that proper and timely operative intervention must be performed with pharmacologic therapy to achieve source control, and that the transition to oral antibiotics should be monitored clinically.…”

A Review of the Clinical Utilization of Oral Antibacterial Therapy in the Treatment of Bone Infections in Adults

“…The oral antibiotics that have been successfully used for jaw osteomyelitis treatment include amoxicillin, amoxicillin/clavulanic acid, clindamycin, moxifloxacin, cotrimoxazole, and penicillin [17]. As for bone and joint infections in the hand, a retrospective study of 61 patients with acute inoculation osteomyelitis of the hand were treated with oral antibiotics for six months; this resulted in a 100% cure rate [11]. The antibiotics used included trimethoprim/sulfamethoxazole, levofloxacin, and moxifloxacin.…”

“…The selection of oral agents should be guided by bioavailability, pharmacokinetic ability to achieve adequate antibiotic concentrations at the site of infection, culture results or local antimicrobial susceptibility profiles if cultures are not available, previous antibiotic response, infection severity, and patient co-morbidities (such as renal function and allergies). Additional benefits include economic advantages [10][11][12][13], improved compliance, comparable efficacy [14,15], and favorable side effect profile [6].…”

“…This variability complicates standardized recommendations for its management, particularly when it comes to the use of oral therapies. The antimicrobials used for bone and joint infections include cotrimoxazole [11,14,16,17], linezolid [16], rifampin [16], fluroquinolones [11,14,17], clindamycin [17], doxycycline [14], amoxicillin [17], amoxicillin/clavulanic acid [17], penicillin [17], and metronidazole [18,19]. The commonly recommended dosing regimens are listed in Table 1.…”

What’s New in Hand and Wrist Surgery

“…The authors found increasing resistance to clindamycin (from 7% to 31%) and to levofloxacin (from 12% to 56%); the risk factors for methicillin resistance were intravenous drug use, hepatitis C, and nosocomial infections for clindamycin and fever and a history of diabetes for levofloxacin. Although intravenous antibiotic administration has been considered the gold standard for the treatment of osteomyelitis, Henry and Lundy 44 demonstrated that patients with acute, direct-inoculation osteomyelitis of the hand could be successfully treated with susceptibility-matched oral antibiotics at a dramatic cost reduction ($482 compared with $21,646 per patient). Understanding poor prognosticators may be helpful in counseling patients and treating infections.…”