Osteomyelitis is an infection of the bone that usually requires surgical intervention. What about the patient who presents with comorbidities that prevent the patient from having surgical intervention? Studies conducted in diabetic foot ulcers have indicated that patients can receive adequate healing of osteomyelitis with antibiotic therapy as opposed to surgical intervention.

Recognizing and Diagnosing Osteomyelitis

Clinical Presentation of Osteomyelitis
How might a patient with a potential osteomyelitis wound present to the clinic? The patient may present with a non-healing wound or recurrent wound that closes and then re-opens. The wound may also manifest with recurrent infection and edema. Any wound with exposed or palpable bone that has been open for greater than six weeks should raise suspicions of osteomyelitis, as should any recurrent or non-healing wound over areas where surgical hardware has been previously placed.

Diagnosis of Osteomyelitis
The gold standard for diagnosing osteomyelitis is a bone culture, which will require an outpatient procedure usually performed using local anesthesia. Some providers begin with a plain x-ray film to rule out other anomalies that could then lead to magnetic resonance imaging, computed tomography, or bone scan for a more definitive view. Laboratory tests that are sometimes utilized include inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein, but these tests have a low specificity when diagnosing osteomyelitis. They can, however, later serve as markers for monitoring the effectiveness of antimicrobial therapy.

Non-Surgical Treatment for Osteomyelitis

Non-surgical treatment of osteomyelitis requires a multidisciplinary team approach including primary care, infectious disease specialist care, nutritionist care and wound care. These wounds will require antibiotic therapy for a duration of six to eight weeks. The antibiotics should be chosen based on the bone biopsy culture and regulated by an infectious disease specialist. The antibiotics initially are delivered parenterally for the first two weeks and then can be managed at home by continuing them either parenterally or orally, depending on the route best suited to the cultured organism and how the infection is responding to the antibiotic. Hyperbaric oxygen therapy has also been proven effective in some cases of osteomyelitis for four to 12 weeks at five days a week. The primary care provider and nutritionist can complement the healing process by focusing on improving comorbidities such as anemia, diabetes mellitus and poor nutrition.

Monitoring Chronic Osteomyelitis
When osteomyelitis has been stabilized with antibiotics and other treatments, it is important to remember that there is always the opportunity for recurrence of the acute infection. The mainstay of treatment of chronic osteomyelitis becomes the stability of the wound, as well as monitoring for recurrence of acute infection. It is important to educate the patient that even though there is no acute infection, there is always the potential for recurrence. The patient should be educated to seek medical care for any change in an area with a history of acute osteomyelitis. The patient should have annual imaging of the area to monitor for changes.

Education
It is important to educate the patient with osteomyelitis that it is a chronic condition necessitating constant monitoring and strict wound care. The patient should be advised that the wound may close but could re-open at some point and most likely could occur in a cyclical fashion. Measures to improve overall health should be discussed, such as smoking cessation, eating a well-balanced diet, glycemic control of hemoglobin A1c <7% and offloading as appropriate.

Conclusion

Patients with osteomyelitis who are not good candidates for surgical treatment may benefit from interdisciplinary medical care, including antibiotic therapy, management of comorbidities and monitoring to prevent recurrence.

Suggested Reading
Dalla Paola LC. Confronting a dramatic situation: the Charcot Foot complicated by osteomyelitis. Int J Low Extrem Wounds. 2014;13(4):247-262.
Lázaro-Martínez J L, Aragón-Sánchez J, García-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: a randomized comparative trial. Diabetes Care. 2014;37:789=795.
Loupa CV, Meimeti E, Voyatzoglou E, et al. Successful nonsurgical therapy of a diabetic foot osteomyelitis in a patient with peripheral artery disease with almost complete radiological restoration. BMC Res Notes. 2018;11(1):579.
Markanday A. Diagnosing diabetic foot osteomyelitis: narrative review and a suggested 2-step score-based diagnostic pathway for clinicians. Open Forum Infect Dis. 2014;1(2):ofu060.
Uckay I, Lew D. Infectious diseases: osteomyelitis. Iinfectious Disease Advisor; 2017. https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medic…. Accessed May 6, 2019.

About the Author
Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN is a Nurse Practitioner at the VA Medical Center in Lake City, Florida. She is the Wound Care Provider in the Out-Patient Clinic serving the Veteran Population of North Florida and South Georgia. Cathy is certified in wound, ostomy and foot care. In addition to her wound care experience, she also has experience in acute care, pediatrics, home health, long-term care and has served as a Professor of Nursing. Cathy’s passion for wound care began while she was working in the long-term care setting as an RN. She serves the veteran population as a memorial to her dad, a combat wounded WWII Veteran.