Primarily non-surgical management of osteomyelitis of the foot in diabetes

Abstract

Aims/hypothesis We examined the use of surgery and assessed the response to non-surgical management of osteomyelitis of the foot in diabetic patients. Methods We reviewed the records of all patients presenting to a single specialist centre with osteomyelitis complicating a diabetic foot ulcer over a 5 year period. Details were extracted on antibiotic choice and treatment duration, hospital admission, incidence of minor and major amputation, and 12 month outcomes. Results There were 147 patients, with mean age 64.7 years (66% men). Of these, 26 (18%) were admitted to hospital at the time of presentation and managed with intravenous antibiotics; the remainder were managed with oral antibiotics as outpatients. Surgery was undertaken because of life-or limb-threatening infection, or failure to respond, in 34 (23%) patients (minor amputation 28, major amputation six patients). The remaining 113 were managed non-surgically. Remission was induced in 66 (58.4% of 113), while 35 (31%) had a relapse. Of those experiencing relapse, 27 (77%) achieved apparent arrest of the infection with a further course of antibiotics; six underwent minor and two underwent major amputation. Of all 113 whose infection was initially managed without surgery, apparent remission was achieved with antibiotics alone in 93 (82.3%). Conclusions/interpretation As these observations were made in an unselected case series, they give more insight into the respective roles of surgical and non-surgical management.The results confirm that although urgent surgery is indicated in some patients, non-surgical management of those without limb-threatening infection is associated with a high rate of apparent remission.

Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement

“…Only 57% of 168 patients with limb salvage had complete healing of the wounds (82% of them remained complicated by osteomyelitis). These results are worse than the new series with a predominantly antibiotic-based treatment of osteomyelitis [11,17]. Where possible, we defend an initial conservative surgical treatment, but the role of this approach is not yet well defined.…”

“…In our series, 64.3% of patients suffered from osteomyelitis in an ischaemic foot. Another recent paper reported an apparent remission in 82.3% patients without surgery [17]. Bone biopsy was not performed but the authors did not exclude ischaemic or elderly patients, thus allowing a complete perspective of the problem.…”

“…Recent series about antibiotic-based treatment defined remission as absence of any sign of infection at the initial or contiguous site [23] or patient survival with limb intact [17]. Another used the term 'healed' with caution because of the potential for osteomyelitis relapse after therapy [11].…”

Application of white blood cell SPECT/CT to predict remission after a 6 or 12 week course of antibiotic treatment for diabetic foot osteomyelitis

“…Despite controversies in the management of DFO, the purely medical approach based on antibiotic therapy alone is efficient [2,3]. Indeed, the remission rate of DFO in those treated medically is reported to range from 53% to 82% [4][5][6][7][8][9][10][11][12][13][14].…”

Osteomyelitis of the foot: non-surgical management, SPECT/CT scanning and minimising the duration of antibiotic use

“…In the meantime, most clinicians pursue a pragmatic approach that relies to a large extent on the resolution of clinical signs of soft tissue inflammation. Game and Jeffcoate reported the use of such an approach in their retrospective review of outcome in 147 consecutive cases with osteomyelitis managed in routine clinical practice in a single centre [10]. A total of 34 of these 147 were judged to require early surgery, while systemic antibiotics (usually oral) were the mainstay of management of the remaining 113.…”