Javier Aragón-Sánchez

Background/Objectives: When presented with chronic osteomyelitis of the adult diabetic foot (DFO), clinicians, patients and their families have two options: rational use of antibiotics or direct surgery. Methods: We conducted a scientific literature review of 118 different articles and administered questionnaires to eighty DFO international and Swiss experts who have already published on the specific choice between a first-line conservative, antibiotic-based therapy versus direct surgery for DFO. Results: According to this specific literature and the ranking of clinical importance, the presence of ischemia came first (91% consensus favoring surgery), followed by the presence of gangrene (94% consensus), the perceived frailty of the patient (80%), sepsis (83%), and major soft tissue loss (81% consensus). Generally, for more than 90% of all experts, gangrene, bone exposed to air, destroyed bone, and hindfoot DFO motivated for direct surgery. We obtained twenty-four questionnaires from colleagues who we addressed as experts. Their opinions aligned with the literature. Compared to the international experts, Swiss clinicians were less hesitant to amputate in case of long-lasting foot ulcers, soft tissue loss, sepsis or patients with a history of low compliance. Combining literature reviews and questionnaires, large necrotic areas and destructed bone may predict direct surgery. Alternatively, clinicians can choose a first-line antibiotic therapy with minimal soft tissue debridement, off-loading and professional wound care. Conclusions: There is no universal consensus. The decision between antibiotics and surgery remains individualized, while severe ischemia, destroyed bone and large tissue loss are predictors of direct surgery; their absence favors antibiotic treatment.

Background/Objectives: When presented with chronic osteomyelitis of the diabetic foot (DFO), clinicians, patients and their families have two options: rational use of antibiotics or direct surgery. Methods: We conducted a narrative, scientific literature review and administered questionnaires to DFO experts to investigate the factors indicating conservative, antibiotic-based therapy vs. direct surgery to treat DFO. Results: If large necrotic areas and destructed bone are present, providers may opt for a direct surgical amputation or internal resection of the infected bone (conservative surgery). Alternatively, they can choose conservative (targeted) antibiotic therapy lasting several weeks, with minimal soft tissue debridement, off-loading and iterative professional wound care. Conclusions: It is difficult to decide between the two treatments. The rationale for choosing either approach is complex, involving many clinical aspects to consider, which we discuss in this article.

OBJECTIVE: The authors hypothesized that prior antibiotic treatment does not reduce culture positivity and that empirical antibiotic therapy in culture-negative cases does not increase the risk of amputation or recurrence in diabetes-related foot osteomyelitis (DFO). METHODS: This retrospective study included 100 consecutive patients with DFO treated at La Paloma Hospital, Diabetic Foot Unit, in Las Palmas de Gran Canaria, Spain, from June 1, 2010, to December 1, 2016. Surgical bone biopsies were obtained for microbiological and histologic analysis. Patients were followed for at least 1 year post-wound healing to monitor infection recurrence. Chi-squared and Fisher exact tests were used to analyze associations between antibiotic use, culture results, amputation, and recurrence. RESULTS: Cultures were negative in 28% of cases. No association was found between prior antibiotic use and negative cultures ( P =.443). Amputation rates were similar in patients with positive (31.9%) and negative cultures (32.1%, P =.98). Infection recurrence occurred in 23% of patients, with no significant difference between positive (26.4%) and negative cultures (14.3%, P =.19). Post hoc power analysis showed 79% power to detect differences in infection recurrence. CONCLUSIONS: Prior antibiotic use did not significantly impact culture positivity in DFO. Empirical antibiotic therapy in culture-negative cases did not increase the risk of amputation or recurrence. Treatment decisions should be individualized, adhering to antimicrobial stewardship principles. Further studies are needed to clarify the relationship between antibiotic exposure, culture results, and outcomes in DFO.

Diabetic foot osteomyelitis is the most frequent infection in diabetes-related foot ulcers, often associated with delayed healing, prolonged hospitalization, and increased risk of amputation. The contribution of microbiological factors to its clinical severity remains uncertain. While severe cases are often associated with soft tissue complications such as abscesses or necrotizing infections, it is unclear whether the bacterial profile influences infection severity. This study aimed to determine whether severe presentations are associated with a higher frequency of polymicrobial infections, multidrug-resistant organisms, or specific bacterial species. We conducted a secondary analysis of a prospective cohort of patients with moderate or severe diabetic foot infections confirmed to involve osteomyelitis through histopathological evaluation. Bacterial species isolated from bone biopsy cultures were compared between moderate and severe cases. Among 114 patients included, 73 were classified as moderate and 41 as severe. Bone cultures were positive in 101 cases, yielding 173 isolates. Staphylococcus aureus was the most frequently isolated species, followed by Enterococcus faecalis and Streptococcus agalactiae . No significant differences were found between severity groups in the distribution of individual species, polymicrobial cultures (46.6% in moderate vs 56.1% in severe; p = 0.435), or multidrug-resistant organisms (12.3% vs 12.2%; p = 1.000). A global comparison of species distribution also showed no statistical association with severity (p = 0.941). These findings suggest that severity is not explained by the microbiological profile identified through conventional aerobic cultures. Instead, host-related or anatomical factors may be more relevant, although the lack of anaerobic cultures may have underestimated microbial diversity.

The optimal method for assessing residual osteomyelitis after conservative surgery for diabetic foot infection remains controversial. Microbiological cultures are frequently used due to their rapid turnaround and utility in guiding antibiotic therapy, but their diagnostic reliability is uncertain. This study compared microbiological cultures and histopathology in evaluating bone resection margins, using histopathology as the gold standard. We included 93 patients undergoing conservative surgery for diabetic foot osteomyelitis. Bone samples were obtained from the proximal resection margin for both microbiology and histopathology. A microbiological result was considered contamination when cultures were positive but histopathology was negative. Microbiological cultures at bone resection margins yielded 52 true positives, 23 false positives (contamination), 10 false negatives, and 8 true negatives when compared to histopathology. This resulted in a sensitivity of 83.9%, specificity of 25.8%, positive predictive value of 69.3%, and negative predictive value of 44.4%. Contamination was not associated with the severity of infection, presence of soft tissue involvement, inflammatory markers, or glycemic control. No association was found between contamination and polymicrobial flora in the primary surgical specimen. However, Pseudomonas aeruginosa was the only species significantly associated with contamination (p = .008), suggesting species-specific factors may contribute to microbiological false positives. These findings emphasize that microbiology, while sensitive, is not a specific method for assessing residual bone infection and should not be used in isolation. Histopathology remains the more reliable diagnostic tool. Future research should explore biofilm-targeted strategies and intraoperative antiseptic protocols to reduce contamination of bone biopsy specimens obtained from resection margins.

The purpose of this study was to examine whether polymicrobial infection in bone biopsies is associated with infection relapse following surgery for diabetic foot osteomyelitis. Relapse of infection presents a major challenge in treating diabetic foot osteomyelitis, yet the role of microbiological factors in predicting relapse remains underexplored. We conducted a retrospective analysis of 100 patients treated surgically for diabetic foot osteomyelitis. Bone biopsies were obtained intraoperatively for microbiological and histopathological examination. Relapse was defined as the recurrence of infection in bone or soft tissue necessitating additional surgical intervention or antibiotic therapy. Our findings indicate that soft tissue involvement, rather than polymicrobial infection in bone biopsies, is a significant predictor of relapse, with patients exhibiting soft tissue involvement showing a markedly higher likelihood of relapse. In contrast, polymicrobial growth in bone biopsies was not significantly associated with infection relapse. These results highlight the importance of soft tissue integrity in treatment outcomes and suggest that local tissue damage, rather than microbiological diversity, may play a more critical role in relapse. This study challenges the assumption that polymicrobial infection directly influences relapse risk and raises questions regarding the reliance on wound healing as an indicator of successful infection management. Future studies should focus on refining treatment indicators and exploring comprehensive approaches that address both bone and soft tissue infections to reduce relapse rates and improve patient outcomes.

Diabetic foot infections (DFIs) and diabetic foot osteomyelitis (DFO) are common and serious complications in patients with diabetes, often leading to severe morbidity (including amputation) and even mortality. Professional footcare, prompt diagnosis and appropriate treatment are crucial to preventing limb loss and improving outcomes in infections. This narrative review addresses the management of all DFIs, including the approach to clinical evaluation, appropriate diagnostic methods, and optimal therapeutic strategies. We specifically address key areas in antibiotic therapy, and surgical interventions and techniques. Based on our literature review and extensive, multidisciplinary experience, we developed a novel treatment flowchart specifically for the management of DFO. Managing DFIs, including DFO, requires a multidisciplinary approach tailored to each patient's clinical presentation. While antibiotics, surgery, and wound care each play a crucial role, the decision-making process should always consider the infection's severity and chronicity. Our proposed flowchart for DFO management emphasizes the importance of logically-sequenced, easy to apply and tailored interventions to prevent unnecessary amputations and improve outcomes. Further research is needed to further refine this flowchart in clinical practice and demonstrate its effectiveness.

Diabetes-related foot osteomyelitis (DFO) can present as an acute condition with soft tissue involvement or as a non-acute form characterized by long-standing ulcers without immediate limb-threatening features. This study evaluates infection relapse and healing times after conservative surgery in non-acute DFO, with a focus on osteomyelitis localization. A retrospective cohort of 60 patients treated for forefoot DFO without soft tissue involvement or necrosis was analyzed. Conservative surgery, defined as resection of infected bone without amputation, was performed in all cases. Postoperative antibiotic therapy was guided by bone biopsy cultures. Infection relapse was defined as new evidence of infection localized to the previously treated bone. Infection arrest was achieved in 98.3% of cases, with a recurrence rate of 10%. Relapse was significantly associated with osteomyelitis localized to the first metatarsal head, which presented a 57.1% relapse rate compared to 3.8% in other locations (OR: 34.0, 95% CI: 4.34–266, p < 0.001). Healing times were longer for the first metatarsal head, first toe, and second to fifth metatarsal heads compared to the lesser toes, but the association with the first metatarsal head lost significance when relapse was included in the analysis. This study highlights the effectiveness of conservative surgery in non-acute DFO, achieving high healing rates while preserving limb function. The findings emphasize the critical role of osteomyelitis localization, particularly the first metatarsal head, in determining relapse and healing outcomes. These results provide a basis for future research into individualized surgical strategies for high-risk anatomical sites.

Aims: We hypothesize that microbiology‐ and pathology‐confirmed positive bone margins after the resection of diabetes‐related foot osteomyelitis are associated with worse outcomes.Methods: We conducted a prospective study consisting of a cohort of 93 patients with diabetes‐related foot osteomyelitis (histopathology confirmed) who underwent bone resection and where an additional bone biopsy was taken at the resection margin. The primary outcome was the recurrence of the infection.Results: Pathology‐confirmed positive margins were detected in 62 cases (66.7%), microbiology‐confirmed positive margins were detected in 75 cases (80.6%) and recurrence was detected in 19 patients (20.4%). Chi‐squared test failed to show the presence of an association between the recurrence of the infection with pathology‐confirmed positive margins (p = 0.82), with microbiology‐confirmed positive margins, (p = 0.34) and with the use of postoperative antibiotics (p = 0.70). Healing in patients with pathology‐confirmed positive margins was achieved in a median of 12 weeks (95% CI 9.2‐18) and those with pathology‐confirmed negative margins in 14.9 weeks (95% CI 10.2‐21.9), Log‐rank test, p = 0.74. Thirty‐four patients out of 61 available for follow‐up (55.7%) with pathology‐confirmed positive margins were treated without postoperative antibiotics. In that group, Chi‐squared test failed to show the presence of an association between the recurrence of the infection with the use of postoperative antibiotics (p = 0.47).Conclusions: A positive margin was neither associated with the recurrence of the infection nor with the time to healing. More than half of patients with pathology‐confirmed positive margins were treated without postoperative antibiotics and this approach was not associated with the recurrence of the infection.