OBJECTIVE: No prospective trials have been carried out comparing antibiotic treatment alone with primarily surgical treatment in patients with diabetes and foot osteomyelitis. The aim of the current study was to compare the outcomes of the treatment of diabetic foot osteomyelitis in patients treated exclusively with antibiotics versus patients who underwent conservative surgery, following up the patients for a period of 12 weeks after healing. RESEARCH DESIGN AND METHODS: Between 1 January 2010 and 31 December 2012, a prospective randomized comparative trial (clinical trial reg. no. NCT01137903, clinicaltrials.gov) of patients with diabetes who had received a diagnosis of neuropathic foot ulcers complicated by osteomyelitis was carried out at the Diabetic Foot Unit at the Complutense University of Madrid. Patients were randomized into the following two groups: the antibiotics group (AG) and the surgical group (SG). Antibiotics were given for a period of 90 days in the AG. Patients in the SG received conservative surgery with postoperative antibiotic treatment for 10 days. RESULTS: Eighteen patients (75%) achieved primary healing in the AG, and 19 (86.3%) in the SG (P = 0.33). The median time to healing was 7 weeks (quartile [Q] 1 to Q5, Q3–Q8) in the AG and 6 weeks (Q1–Q3, Q3–Q9) in the SG (P = 0.72). The conditions of four patients from the AG worsened (16.6%), and they underwent surgery. Three patients from the SG required reoperation. No difference was found between the two groups regarding minor amputations (P = 0.336). CONCLUSIONS: Antibiotic therapy and surgical treatment had similar outcomes in terms of healing rates, time to healing, and short-term complications in patients with neuropathic forefoot ulcers complicated by osteomyelitis without ischemia or necrotizing soft tissue infections.

Infection is a common epiphenomenon of advanced diabetic foot disease and the most common reason for diabetes-related hospitalizations and lower extremity amputations. Major advances have been made in the past three decades in our understanding and management of diabetic foot infections (DFIs). The optimal treatment of DFIs clearly involves multidisciplinary input. A comprehensive search of the literature on DFIs from January 1960 through June 2015 was performed, with an emphasis on information published in the past 30 years. There have been many new insights into the microbiology, diagnosis, and treatment of DFIs, although the implementation of this knowledge in clinical practice has been suboptimal. Today, the use of evidence-based guidelines, multidisciplinary teams, and institution-specific clinical pathways helps guide optimal care of this multifaceted problem. Patients are more often treated in the ambulatory setting, with antibiotic regimens that are more targeted, oral and shorter course, and with more conservative (but earlier) surgical interventions. New diagnostic and therapeutic methods are being developed at an accelerating pace. The worldwide increase in the incidence of diabetes and longer lifespan of diabetic patients will undoubtedly increase the incidence of DFIs. Clinicians caring for diabetic patients should have an understanding of current methods for preventing, diagnosing, and treating DFIs.