Treatment algorithms for chronic osteomyelitis

Osteomyelitis was described many years ago but is still incompletely understood. Its exogenously acquired form is likely to become more common as the population ages. We discuss biofilm formation as a clinically relevant pathophysiological model and present current recommendations for the treatment of osteomyelitis.

We selectively searched the PubMed and Cochrane databases for articles on the treatment of chronic osteomyelitis with local and systemic antibiotics and with surgery. The biofilm hypothesis is discussed in the light of the current literature.

There is still no consensus on either the definition of osteomyelitis or the criteria for its diagnosis. Most of the published studies cannot be compared with one another, and there is a lack of scientific evidence to guide treatment. The therapeutic recommendations are, therefore, based on the findings of individual studies and on current textbooks. There are two approaches to treatment, with either curative or palliative intent; surgery is now the most important treatment modality in both. In addition to surgery, antibiotics must also be given, with the choice of agent determined by the sensitivity spectrum of the pathogen.

Surgery combined with anti-infective chemotherapy leads to long-lasting containment of infection in 70% to 90% of cases. Suitable drugs are not yet available for the eradication of biofilm-producing bacteria.