The principle of treatment
is to administer antibiotics
while providing a local
environment in which they
can work. This typically
involves the removal of dead
soft tissue and accessible
dead bone during the wound
care process. These
interventions may be
undertaken by any
appropriately trained
healthcare provider.
Surgical
procedures
for removing necrotic
and infected bone range
from simple outpatient
debridement to major
amputation.
Urgent surgery
is indicated for
necrotising
fasciitis, deep soft
tissue abscess or
gangrene
accompanying
osteomyelitis. All
systemically unwell
patients should be
evaluated with these
possible diagnoses
in mind.
Non-urgent
surgery may be
necessary if there
is significant
compromise of the
soft tissue
envelope, loss of
mechanical function
or integrity of the
foot, when the
degree of bone
involvement is
likely to threaten
life or limb, or
where patient or
provider wish to
avoid prolonged
antibiotic therapy.
Otherwise,
surgical debridement
of infected bone
appears not to be
necessary in some
cases of diabetic
foot osteomyelitis,
though one cannot
predict with
certainty which
patients will fail
medical therapy.
Antibiotic
regimens
should be as
targeted and narrow
spectrum as possible.
Bone culture and
sensitivity results, if
obtained, can assist in
achieving this goal.
No specific
agent has been shown
to be most effective
for osteomyelitis.
Empiric regimens
must include
anti-staphylococcal
coverage, with
activity against
methicillin-resistant
strains (MRSA)
according to local
prevalence data.
Achieving
adequate levels of
antibiotics in the
infected bone can be
accomplished with
intravenous therapy
or highly
bioavailable oral
antibiotics. There
are no data to
indicate the
superiority or
inferiority of any
particular route of
delivery of systemic
antibiotic for
treating
osteomyelitis.
Available data are
insufficient to
assess the efficacy
of locally
administered
antibiotics.
There are also
no data to inform
decisions on
duration of
antibiotic therapy.
The scheme produced
by the Infectious
Diseases Society of
America, which
assesses the extent
of residual soft
tissue infection,
bone infection and
dead bone, and
adjusts duration
accordingly, appears
to be useful.
Adjunctive
treatments
Limb ischaemia
considered critical
or compromising of
wound healing should
be corrected through
revascularisation
procedures.
There is no
evidence to support
the use of
hyperbaric oxygen
G-CSF or larval
therapy in the
treatment of
diabetic foot
osteomyelitis.
