The choice of antibiotic regimens for use in patients presenting with diabetic foot osteomyelitis and their duration differs according to the situation. Antibiotics play a more important role in the medical option where no infected bone has been resected, while their role is reduced but not negligible in the case of surgical options. Some studies have reported the presence of biofilm structures in bone samples taken from patients with diabetic foot osteomyelitis, which raises the question of the place of anti-biofilm antibiotic regimens in this setting. During the last two decades, clinical studies have suggested a potential benefit for anti-biofilm antibiotics, mainly rifampicin against staphylococci and fluoroquinolones against gram-negative bacilli. However, no data from randomized controlled studies have been reported so far. The present work provides a summary of the available data on the question of the place of anti-biofilm antibiotics for the treatment of diabetic foot osteomyelitis, but also the potential limitations of such treatments.

Introduction: Osteomyelitis is a severe complication of diabetes-related foot ulcers (DFUs) often managed with antibiotic therapy and surgical resection of the infected bone. Areas of research: While intravenous (IV) antibiotics have been the traditional approach for bone and joint infections in general, randomized clinical trials have shown that, overall, oral antibiotics are non-inferior to IV antibiotics. While comparisons between oral antibiotics are generally lacking, the data suggest that oral antibiotics with high bioavailability and bone penetration ratios should be prioritized for osteomyelitis treatment, including diabetic foot osteomyelitis (DFO). Oral regimens reduce hospital stays, avert catheter-related complications, and decrease treatment costs while improving patient satisfaction and quality of life. Despite these advantages, IV antibiotics remain widely used, partly due to clinical tradition and concerns about oral absorption in individuals with diabetes. Current guidelines recommend transitioning to oral therapy once systemic signs improve, but robust data supporting oral-only regimens for DFO treated non-surgically remain limited. Conclusions: Oral antibiotics represent a safe and effective alternative to IV therapy for many patients with DFO, particularly when high-bioavailability agents are used. Further well-designed studies are needed to validate their efficacy in non-surgical DFO management and inform clinical guidelines.

The choice of antibiotic regimens to use in patients presenting with diabetic foot osteomyelitis and their duration differs according to the situation. Antibiotics play a more important role in the medical option where no infected bone has been resected while their role is reduced but not negligible in the case of surgical options. Some studies have reported the presence of biofilm structures in bone samples taken from patients with diabetic foot osteomyelitis which raises the question of the place of anti-biofilm antibiotic regimens in this setting. During the last two decades, clinical studies have suggested a potential benefit for anti-biofilm antibiotics, mainly rifampicin against staphylococci and fluoroquinolones against gram-negative bacilli. No data from randomized controlled studies have however been reported so far. The present work provides a summary of the available data on the question of the place of anti-biofilm antibiotics for the treatment of diabetic foot osteomyelitis but also the potential limitations of such treatments.