{"id":2793,"date":"2019-08-29T08:31:59","date_gmt":"2019-08-29T13:31:59","guid":{"rendered":"https:\/\/blog.unmc.edu\/infectious-disease\/?p=2793"},"modified":"2024-09-24T11:02:13","modified_gmt":"2024-09-24T16:02:13","slug":"treatment-of-osteomyelitis-whats-the-evidence-for-our-strategies","status":"publish","type":"post","link":"https:\/\/blog.unmc.edu\/infectious-disease\/2019\/08\/29\/treatment-of-osteomyelitis-whats-the-evidence-for-our-strategies\/","title":{"rendered":"Treatment of Osteomyelitis – What’s the Evidence for our Strategies?"},"content":{"rendered":"

New UNMC ID publication alert! #ReadUNMCID<\/strong><\/p>\n

\"\"Recently, the newest member of our Division of Infectious Diseases at UNMC\/Nebraska Medicine, Dr. Nicolas Cortes-Penfield published an invited review in Open Forum Infectious Diseases entitled: The History of Antibiotic Treatment of Osteomyelitis<\/a>.\u00a0 Dr. Cortes-Penfield wrote this summary describing the review article, which was commissioned after he published a comprehensive blog post (on his blog IDJournalClub.com) about the history of osteomyelitis, with a robust twitter response<\/a> to the topic.<\/em><\/p>\n

What is the study about?<\/strong><\/p>\n

The impetus for this study was the recently published OVIVA trial, which showed equivalent outcomes with oral versus intravenous antibitoics for bone and joint infections.\u00a0 This was a large and really well-designed randomized clinical trial \u2013 in our minds, one of the best clinical trials ever published in bone and joint infection research.\u00a0 Yet, we observed that many infectious disease specialists did not feel that OVIVA represented enough evidence to change the way they treat these infections.\u00a0 So we asked ourselves, \u201cWhat exactly is the quality of the evidence for the way we\u2019ve been doing things?\u201d<\/p>\n

In our study, we laid out some of the most commonly taught tenets of treating bone infections (osteomyelitis) and then conducted a narrative historical literature review reaching back to the beginning of the antibiotic era to try to tease out where these teachings came from and which ones were backed by high quality evidence (like clinical trials) versus simply expert opinion and tradition.<\/p>\n

What did the study find?<\/strong><\/p>\n

As we reviewed the literature, we focused on three classical teaching points for osteomyelitis: that certain antibiotics are better for these infections because they concentrate in the bones, that intravenous antibiotics give better results than antibiotics given by mouth, and that osteomyelitis needs to be treated with antibiotics for four to six weeks.<\/p>\n

We found that the research on antibiotic bone penetration was heterogenous, and that with the exception of the penicillins and cephalosporins there wasn\u2019t compelling evidence that the antibiotic classes achieve different concentrations in bone.\u00a0 Moreover, the studies that generated the theory that antibiotics with better bone penetration treated osteomyelitis more effectively were done in animals; we could not find any robust data in people to support this notion.<\/p>\n

\"\"As for the universal necessity of giving antibiotics intravenously for osteomyelitis, we were surprised to find that many of the first reports of antibiotic treatment of bone and joint infections used oral penicillins and other agents, with excellent results.\u00a0 Moreover, when retrospective studies and prospective clinical trials compared specific antibiotics head-to-head, the patients given antibiotics by mouth did just as well as those who received antibiotics intravenously.\u00a0 This was true of multiple studies including both children and adults, and is important because it shows us that the OVIVA study is not the outlier in this body of literature, but rather an extension of what the preponderance of data in people has been telling us all along.<\/p>\n

As for the necessary duration of therapy in osteomyelitis, we were surprised by how little evidence we could turn up on this topic.\u00a0 Again, physicians in those earliest reports often used just a couple of weeks of therapy, and most often let their patients\u2019 conditions (e.g. the presence of fever) guide the duration of antibiotic treatment.\u00a0 As best we could determine, a chart study of bone and joint infections published in the New England Journal of Medicine, in which the authors reviewed 62 osteomyelitis cases at their hospital to conclude that patients who received at least a month of antibiotics were more likely to respond well to treatment, seems to have originated what is a now universal dogma.\u00a0 In fact, we located more recent data showing that children with acute osteomyelitis do well with less than three weeks of antibiotic treatment, as well as studies suggest that eight or more weeks of therapy may be better for adults with osteomyelitis and certain high-risk features like ESRD, infection with Methicillin-Resistant Staphylococcus aureus<\/em>, and undrained paravertebral abscess.\u00a0 So, what we can say with confidence is that this question hasn\u2019t been adequately studied, and how long a course of antibiotics a patient needs probably depends on who they are.<\/p>\n

Why is this study interesting?<\/strong><\/p>\n

\"\"This study lays bare the scarcity of data on which several of our current traditions regarding treating osteomyelitis are based.\u00a0 Medicine is a field with a lot of cultural inertia \u2013 which makes sense, in that when you\u2019re making high-stakes decision there\u2019s a natural bias to keep doing what you\u2019ve seen work before and what your mentors told you worked best for them.\u00a0\u00a0 So, in order for us as a medical community to embrace evidence-based medicine, we need more than just better clinical science; we need a shift away from reliance on tradition and deference to hierarchies of eminence (i.e.; \u201cThat\u2019s always how we\u2019ve done it here\u201d) and toward a culture of skepticism and interrogation of clinical pearls that don\u2019t come with references cited.\u00a0 We hope this study \u2013 whose narrative structure we intended to help the reader grasp the humble origins of some of the clinical dictums they were taught \u2013 will do a little to shift the infectious diseases community toward a culture of evidence-based medicine.<\/p>\n

What about future research questions?<\/strong><\/p>\n

We could answer this question two ways.\u00a0 First, with the field of osteomyelitis, some obvious next questions are whether certain antibiotic combinations might be more effective at achieving clinical cure without recurrence (i.e.; the use of adjunctive rifampin, currently undergoing a large randomized controlled trial) and what patient and infection factors identify people with osteomyelitis who will do just as well with less than four weeks of antibiotic therapy, or conversely who would really benefit from longer than six weeks of antibiotics.\u00a0 Second, there are plenty of other infections with current standards of treatment based in expert opinion that would benefit from the historical narrative review treatment.<\/p>\n