Antibiotics for treating chronic osteomyelitis in adults

Conterno LO, da Silva Filho CRodrigues

Published Online:

July 8, 2009

Osteomyelitis is an inflammation of the bone and bone marrow caused by pus-forming bacteria, mycobacteria or fungi. All bone infection that is long-standing is called chronic osteomyelitis. Antibiotics can be administered either orally or parenterally (i.e. by any route other than the mouth or bowel). This review identified eight small randomised trials which presented results for a total of 228 patients, most of whom were reported to have had surgical removal of the infected tissue (debridement) before starting on antibiotic therapy. There were four comparisons but pooling of results was only possible for the comparison of oral versus parenteral administration of antibiotics. Pooled results from three trials showed no statistically significant differences in the numbers of people who were without symptoms (in 'remission') at 12 months or more follow-up; nor in numbers with adverse effects or with a superinfection (another infection that is not sensitive to the antibiotic being used). This evidence suggests that the method of antibiotic administration does not have an impact on the rate of disease remission if the bacteria causing the infection are sensitive to the antibiotic used. However, confirmation is needed. There was either no or insufficient evidence to inform on the optimal duration of antibiotic therapy and on types of antibiotics.

Abstract (click to read)

Background:

Chronic osteomyelitis is generally treated with antibiotics and surgical debridement but can persist intermittently for years with frequent therapeutic failure. Despite advances in both antibiotics and surgical treatment, the long-term recurrence rate remains at approximately 20% to 30%.

Objectives:

To determine the effects of different systemic antibiotic treatment regimens for treating chronic osteomyelitis in adults.

Search strategy:

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3), MEDLINE (January 1966 to October 2008), EMBASE (January 1980 to October 2008), LILACS (October 2008) and reference lists of relevant articles.

Selection criteria:

Randomised or quasi-randomised controlled trials addressing the effects of different antibiotic treatments given after surgical debridement for chronic osteomyelitis in adults.

Data collection and analysis:

Two authors independently screened papers for inclusion, extracted data and appraised the quality of included trials. Where appropriate, we pooled data using the fixed-effect model.

Main results:

We included eight small trials (257 participants in total, with data available from 228). Study quality was often inadequate: in particular, concealment of allocation was not confirmed and there was an absence of blinding of outcome assessment. The antibiotic regimens, duration of treatment and follow-up varied between trials. Five trials compared oral versus parenteral antibiotics. There was no statistically significant difference between the two groups in the remission rate 12 or more months after treatment (risk ratio 0.94, 95% confidence interval 0.78 to 1.13; 3 trials). Antibiotic treatment for osteomyelitis was associated with moderate or severe adverse events in 4.8% of patients allocated oral antibiotics and 15.5% patients allocated parenteral antibiotics (risk ratio: 0.40, 95% confidence interval 0.13 to 1.22; 4 trials). Single trials with very few participants found no statistical significant differences for remission or adverse events for the following three comparisons: parenteral plus oral versus parenteral only administration; two oral antibiotic regimens; and two parenteral antibiotic regimens. No trials compared different durations of antibiotic treatment for chronic osteomyelitis, or adjusted the remission rate for bacteria species or severity of disease.

Authors' conclusions:

Limited evidence suggests that the method of antibiotic administration (oral versus parenteral) does not affect the rate of disease remission if the bacteria are sensitive to the antibiotic used. However, this and the lack of statistically significant differences in adverse effects need confirmation. No or insufficient evidence exists for other aspects of antibiotic therapy for chronic osteomyelitis.

This record should be cited as:

Conterno LO, da Silva Filho CRodrigues. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD004439. DOI: 10.1002/14651858.CD004439.pub2

Assessed as up to date:

December 1, 2008

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Primary Review Group:

Bone, Joint and Muscle Trauma Group

Health topics:

Orthopaedics & trauma > Fractures > Bones of appendicular skeleton

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Independent high-quality evidence for health care decision making

Antibiotics for treating chronic osteomyelitis in adults

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