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Medical or Surgical Therapy for Diabetic Foot Osteomyelitis?

Summary and Comment |
April 8, 2014

Medical or Surgical Therapy for Diabetic Foot Osteomyelitis?

  1. Allan S. Brett, MD

In selected patients with localized infections, outcomes were comparable with the two approaches.

  1. Allan S. Brett, MD

Patients with diabetic foot infections and associated osteomyelitis can be treated medically or surgically, but randomized trials to guide this decision are lacking. In this study from Spain, 52 diabetic patients with neuropathic foot ulcers complicated by osteomyelitis were randomized to receive either a 90-day course of antibiotics or “conservative surgery” (i.e., removal of infected bone without performing amputation) followed by 10 days of antibiotic therapy. In all patients, antibiotic therapy was guided by deep soft-tissue cultures. Patients with severe soft-tissue infections, substantial peripheral arterial disease, or exposed bone at the bottom of ulcers were excluded. Forty-six patients completed the study.

Primary healing (i.e., complete epithelialization of the ulcer or surgical wound) occurred in 75% of patients in the antibiotic group and in 86% of those in the surgical group (P=0.33). During 12 weeks of observation, four antibiotic patients required surgery, and three surgery patients required reoperation; reulceration without osteomyelitis occurred in two and four patients, respectively.

Comment

This study — the first such randomized trial, according to the authors — suggests that a long course of antibiotic therapy compares favorably with surgery plus short-course antibiotic therapy in highly selected patients with diabetic foot ulcers and osteomyelitis. Obvious limitations are the trial's small size and relatively brief follow-up. A recent guideline from the Infectious Diseases Society of America is an excellent resource for clinicians who care for these patients (Clin Infect Dis 2012; 54:e132).

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose

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