Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update

Abstract

Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, “conservative” surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.

Minimally Invasive Metatarsal Osteotomies (MIMOs) for the Treatment of Plantar Diabetic Forefoot Ulcers (PDFUs): A Systematic Review and Meta-Analysis with Meta-Regressions

“…Relating to the severity of the ulcers, based on their clinical experience [6,27], the authors strongly believe that MIMOs can be an alternative valid treatment also for PDFUs with chronic infection, ulcers penetrating deep structures (IIIB), and ulcers with osteomyelitis of the metatarsal bones or the proximal phalanx. These challenging feature presentations, or evolution of diabetic feet, becoming increasingly frequent, in association to other vascular complications, such as ankle brachial index below 0.5 or flat pulse volume recording at the ankle level, should be considered as relative, but not absolute, contraindications for MIMOs [6,52]. As the PDFU represents the main access door for the bacteria causing foot osteomyelitis, resolving the first promotes the healing of the second, avoiding long-term antibiotic therapy, which causes progressive bone damage in diabetic patients [53].…”

Conservative surgical treatment for metatarsal osteomyelitis in diabetic foot: experience of two French centres

“…One of the most feared complications of DFO is lower extremity amputation 2,3 . The choice of medical or surgical treatment of DFO is still subject to debate 4 . Medical treatment of DFO without surgery can be an option in selected indications, with antibiotic therapy guided by microbiological results of bone biopsy 5 .…”

Epidemiology and outcomes of bone and joint infections in solid organ transplant recipients

“…42,50 Only difficult-to-operate osteomyelitis and DFO might have higher risks of failure. 51,52 The less favorable clinical outcomes observed in this cohort could, in part, be explained by the concomitant comorbidities and administration of immunosuppressive treatments in SOTr, potentially hindering tissue healing, and/or the rather indolent clinical presentation of BJI in this population.…”