Changing the Osteomyelitis Paradigm

Dear Reader:

For most of us, the dogma of treating osteomyelitis for our entire practice life has been intravenous antibiotics for 6 weeks. The majority of wound medicine practitioners see an abundance of osteomyelitis of the foot, while others of us also see postoperative and pressure- or periprosthetic-related osteomyelitis. The Infectious Diseases Society of America (IDSA) recommendations 7 through 10 for the diagnosis of osteomyelitis make sense, although we must remember the relatively low level of evidence:

Recommendation 7

In a person with diabetes, consider using a combination of probe-to-bone test, plain X-rays, and ESR, or CRP, or PCT as the initial studies to diagnose osteomyelitis of the foot. (Conditional; Low).

Recommendation 8

Perform magnetic resonance imaging (MRI) when the diagnosis of diabetes-related osteomyelitis of the foot remains in doubt despite clinical, plain X-rays and laboratory findings. (Strong; Moderate).

Recommendation 9

Consider using positron emission tomography (PET), leucocyte scintigraphy, or single photon emission computed tomography (SPECT) as an alternative to MRI for the diagnosis of diabetes-related osteomyelitis of the foot. (Conditional; Low).

Recommendation 10

In a person with diabetes for whom there is a suspicion of osteomyelitis of the foot (before or after treatment), bone (rather than soft tissue) samples should be obtained for culture, either intraoperatively or percutaneously. (Conditional; Moderate).¹

In general, diagnosing osteomyelitis for the lowest cost makes the most sense.  However, the IDSA’s Recommendation 16, “Consider a duration of up to 3 weeks of antibiotic therapy after minor amputation for diabetes-related osteomyelitis of the foot and positive bone margin culture and 6 weeks for diabetes-related foot osteomyelitis without bone resection or amputation. (Conditional; Low),” gives us all an opportunity for improvement.  The changing paradigm includes the potential to deliver reconstructive/absorbable/dissolvable high-dose antibiotic to the infected site.  To date, the market leader in this area has reported (though not yet published) improved 5-year survival and improved amputation-free survival, and they have published a 94% osteomyelitis eradication.^2,3

Now with several other companies in the hunt, various delivery platforms and potentially effective local therapies are on the forefront of a breakthrough.  As the evidence mounts to support these local therapies, it will be imperative that we (the wound care community) work with the IDSA and other recognized organizations that develop and promote these guidelines to incorporate the best clinical algorithms for our patients with acute and chronic osteomyelitis.  The opportunity to prolong life and not have to resect foot (and other) bones may be on the immediate horizon.  I, for one, look forward to the completion of Phase 2 and 3 clinical trials in the effect of local antimicrobial delivery therapies on limb salvage while seeing others start on their journey down this potentially paradigm-shifting pipeline.  Some of our colleagues have started rolling out these algorithms that replace resecting with reinforcing the bone(s). Keep an eye out for their outcomes to be published in this Journal.

1. Senneville E, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Clin Infect Dis. Published online October 2, 2023. doi:10.1093/cid/ciad527.

2. McNally MA, Ferguson JY, Scarborough M, Ramsden A, Stubbs DA, Atkins BL. Mid- to long-term results of single-stage surgery for patients with chronic osteomyelitis using a bioabsorbable gentamicin-loaded ceramic carrier. Bone Joint J. 2022;104-B(9):1095-1100. doi:10.1302/0301-620X.104B9.BJJ-2022-0396.R1.

3. Elkady R, McHugh S, Kheirelseid E, et al. The role of Cerament (antibiotic impregnated bone void filler) in lower limb salvage for diabetic foot patients with osteomyelitis, a scoping review. Surgeon. 2026;24(2):126-136. doi:10.1016/j.surge.2025.09.001.