It has been a little while since I asked a clinical question of you, the readers.  I actually received a pretty good response last time and some interesting thoughts so I figured I would post a question that was recently asked of me: 

“What is your opinion on the ‘standard of care’ of the need for serial imaging (x-rays in particular but also possibly MRI or nuclear scans can be considered) in a chronic plantar wound, in a patient with diabetes?  The wound does not probe and there are no signs of clinical infection.  The wound is probably not healing because of non-adherence with off loading instructions. How often would you order the different imaging studies?”

The reason I am bringing this up to you is that I think it is a really interesting question.  What do you think?  Please respond and let me know.  After I hear from you, I will try to give you my thoughts on it.

I have blogged a number of times about the questions surrounding some of the unknown, unproven issues surrounding the treatment of osteomyelitis including duration of antibiotic therapy and the “need” for surgical debridement. It continues to amaze me how it does not matter where, or to whom I lecture, if I ask the question “How long do you need to treat osteomyelitis and via what route?” the answer is always the same “4-6 WEEKS OF IV THERAPY” despite a total lack of human evidence to support that position. I recently came across an interesting paper that add to the ever increasing body of scientific literature that shows this old axiom is just not justified.   

In the February 2011 issue of International Orthotpedics T. Rod-Fleury and colleagues looked at duration of post surgical antibiotic therapy in adult chronic osteomyelitis.  (http://www.ncbi.nlm.nih.gov/pubmed?term=Rod-Fleury%20T) This is from the same group at Geneva University Hospital that published on the utility of sinus tract cultures on which I commented back in November of this past year.  They retrospectively examined 49 episodes of chronic osteo with a minimum of 2 years follow-up.  I should point out that they specifically excluded diabetic foot osteo.   The patients underwent a median number of 2 surgical debridements.  These were bad cases with almost all being considered Cierny-Mader IV category disease with the patients having a minimum duration of symptoms of 3 months. They found that 80% were in remission at the two year point.  What I feel is important to stress is their conclusion right from the Abstract that, after multivariate logistic regression analysis “one week of intravenous therapy had the same remission as two to three weeks or ≥ 3 weeks.  More than six weeks of total antibiotic treatment equaled ≤ six weeks.”  To quote the conclusion of the paper “If our retrospective results are confirmed, a shorter or oral antibiotic treatment post-debridement could further decrease antibiotic consumption, as well as the related costs, adverse effects and selective pressure for resistant bacterial pathogens.”  Now, this is far from a perfect study and the authors do a commendable job citing the limitations of the study.  Also, they take the almost chauvinistic surgical attitude right in the beginning of the Introduction that “Chronic bacterial osteomyelitis is a surgical disease” (still not totally proven in my mind), but it does again bolster the argument that we need to re-examine this entire 4-6 week IV dogma.