We have all been taught, and the literature supports, that osteomyelitis can be treated with long doses of IV antibiotics or surgical debridement. In addition, it has been my experience that patients are often sent out on IV antibiotics upon discharge despite clean margins being obtained via serial surgical debridement.

Following conventional wisdom, it seems that it is prudent to maintain patients with diabetic foot infections and concomitant osteomyelitis on some treatment regimen of antibiotics following surgical debridement to prevent the risk of continued infection should bacteria remain in the wound despite a clean pathology or culture report.

What are your thoughts on this topic? Is it necessary to prophylactically treat patients with IV antibiotics following surgical debridement, as opposed to dosing patients with high doses of oral antibiotics? And if so, for how long? If clean margins are obtained, should they be dosed at all?

Great topic. There are several things we should consider. Bacteria is always present in the wound as it would be on bone if it is exposed. Question is whether the bacteria is pathogenic and whether it is IN the bone (histologic presence of polymorphonucleocytes in the medullary space). The gray area is how long does the bacteria need to sit on bone before it becomes infected. However, once the focus of infection is eliminated via surgical resection and proven by histologic clean margins, some infectious diseases specialists only recommend 7-10 days of antibiotics (PO or IV depending on the pathogenic organism) after delayed primary closure to address residual bacteria presence in the wound. Sometimes, in an open resection they may recommend discontinuing antibiotic therapy as the main focus of infection has been eliminated. Bottom line: Do not doubt when it is out. If the bone infection is eliminated, no need for long term antibiotic therapy for the bone. Then the overall duration of antibiotic treatment is focused on the soft tissue infection.

My opinion on this one is that we generally overtreat / overprescribe antibiotics when discharging these patients. This probably stems from mediolegal concerns. I agree with Dr. Liu that if you cut our the infection, a short course of antibiotics should be sufficient. Overprescribing antiobiotics places these patients at greater risk for resistance, C Diff, thrombocytopenia, etc.

Agree with the above responders. IDSA guidelines state that if the osteomyelitic bone is removed, soft tissue infection therapy (up to 14 days) using antibiotics are sufficient. Perfect example is a forefoot osteomyelitis and a TMA is performed. 2 weeks of antibiotics to treat the remainder of the soft tissue is plenty.