Changing the Paradigm for Osteomyelitis: Insights from SAWC

Hi, my name is Dr. Warren Joseph. I'm a podiatrist specializing in infectious diseases, currently practicing in Sedona, Arizona, even though most of my career I was in the Philadelphia area.

I'm also the first podiatrist elected as a fellow of the Infectious Diseases Society of America, and I'm one of the authors of the IDSA Diabetic Foot Infection Guidelines Committee. Currently, I'm an adjunct clinical professor at the Arizona College of Podiatric Medicine in Glendale, Arizona. So, I've been treating wounds, diabetic foot infections, et cetera, for over 40 years now. 

Doesn't matter where I lecture in the world or to what specialty I lecture, if I ask the audience, how do you treat osteomyelitis, or what's the so-called standard of care for treating osteomyelitis? The answer is always the same. You need 6 weeks of IV antibiotics, and that has to be following aggressive surgical debridement. Well, do you know that the whole 6 weeks of IV antibiotic thing is not based in any human evidence whatsoever? In fact, there's better evidence to show that we can use oral antibiotics, we don't need 6 weeks, and we don't need surgical debridement. So, you have to question all 3 of those major factors that are put into that standard of care equation. You have to question the use of IV antibiotics, you have to question that you need 6 weeks, and you have to question the need for surgical debridement. And that's what I do in the lecture I'm giving at SAWC this year.

You know, there's been a lot, and that's all been within the last 10 years or so. A lot of it is out of Europe, some of it coming out of the States. Whereas, up to that point, before 10 years ago, we had very, very little good evidence on the treatment of osteomyelitis. But a lot of that turned back about 3 years ago now when the OVIVA trial was published in the New England Journal of Medicine. OVIVA and what they found in almost 1,500 patients, they found there was no difference in outcomes in patients treated with IV antibiotics versus those treated with oral antibiotics. And even more recently, about a year and a half ago or so, Dr. Brad Spellberg, whose chief medical officer at USC Keck in Los Angeles, published a beautiful systematic review with meta-analysis on the use of oral antibiotics versus IV for the treatment of not only osteomyelitis, but even bacteremia. In fact, the title of the article, I think it was published in the American Journal of Medicine, was "Oral is the New IV." I love that name. And what he basically showed was that there is not a single study in the world literature to show that IV antibiotics are somehow better or superior than oral antibiotics in the treatment of osteomyelitis. And that was supported by his meta-analysis. So the data is really, really clear now. Oral antibiotics work well. And there have been a number of studies now that have looked at what is called conservative surgery versus ablative surgery. So instead of doing an amputation, just doing a local debridement of the bone, that has shown that that works every bit as well as aggressive surgical debridement. So, you can get away with either minimal surgery to even no surgery and have the same outcomes as if you did an ablative procedure and actually removed a part.

So the literature is really interesting in this regard. Yet the average infectious disease specialist, the average practitioner, podiatrist, wound care specialist, orthopedist, whatever, continues to have in the back of their mind that you need to use 6 weeks of IV antibiotics and surgical debridement, and the evidence does not support that.