From the Guidelines
Diagnosing and managing osteomyelitis in diabetic patients should begin with a thorough clinical examination, followed by imaging studies, including plain radiographs and MRI, and microbiological diagnosis using bone biopsy with culture, as recommended by the most recent guidelines 1. To diagnose osteomyelitis in diabetic patients, the following steps should be taken:
- Perform a thorough clinical examination, looking for signs of infection such as erythema, warmth, purulent discharge, exposed bone, or a non-healing ulcer.
- Use a combination of probe-to-bone test, plain X-rays, and ESR, or CRP, or PCT as the initial studies to diagnose osteomyelitis of the foot, as suggested by the guidelines 1.
- Consider using MRI when the diagnosis of diabetes-related osteomyelitis of the foot remains in doubt despite clinical, plain X-rays and laboratory findings, due to its high sensitivity and specificity 1.
- Obtain bone (rather than soft tissue) samples for culture, either intraoperatively or percutaneously, to identify the causative organism and guide antibiotic therapy, as recommended by the guidelines 1. Some key points to consider in the management of osteomyelitis in diabetic patients include:
- Using conventional, rather than molecular, microbiology techniques for the first-line identification of pathogens from soft tissue or bone samples 1.
- Administering antibiotic therapy for a duration of 1–2 weeks, with the possibility of extending treatment up to 3–4 weeks if the infection is improving but is extensive and is resolving slower than expected, or if the patient has severe peripheral artery disease (PAD) 1.
- Re-evaluating the patient and reconsidering the need for further diagnostic studies or alternative treatments if evidence of infection has not resolved after 4 weeks of apparently appropriate therapy 1.
From the Research
Diagnosis of Osteomyelitis in Diabetic Patients
- Osteomyelitis is a complication of diabetic foot infection, and its diagnosis is crucial for effective management 2, 3, 4, 5, 6.
- The diagnostic value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in detecting osteomyelitis in diabetic patients has been evaluated in several studies 2, 3, 4, 5, 6.
- A study found that the area under the ROC curve of ESR in detection of osteomyelitis in diabetic foot cases was 0.70, with a best ESR cut-off point of 49 mm/hour 2.
- Another study found that the optimal cutoff values for ESR and CRP to diagnose osteomyelitis in patients with diabetes-related foot infections were 60 mm/h and 7.9 mg/dL, respectively 4.
- Procalcitonin (PCT) has also been investigated as a novel infection marker for the diagnosis of osteomyelitis in diabetic foot patients, with a study finding that PCT levels were significantly higher in patients with osteomyelitis 6.
Management of Osteomyelitis in Diabetic Patients
- The management of osteomyelitis in diabetic patients involves a combination of medical and surgical interventions 3, 5.
- ESR and CRP can be used to monitor treatment outcomes in diabetic foot osteomyelitis, with stagnating values of these markers associated with poor clinical outcomes 5.
- A study found that factors associated with diabetic foot osteomyelitis (DFO) remission included a lower white blood count at admission and a higher glomerular filtration rate 5.
- The use of ESR, CRP, and PCT as markers of osteomyelitis in diabetic patients can help guide treatment decisions and improve patient outcomes 2, 3, 4, 5, 6.
Clinical Findings and Imaging Studies
- Clinical findings, such as wound characteristics and patient history, can be used in conjunction with laboratory tests and imaging studies to diagnose osteomyelitis in diabetic patients 4, 6.
- Imaging studies, such as MRI and plain x-rays, can be used to confirm the diagnosis of osteomyelitis and guide treatment decisions 2, 3, 4, 6.
- A diagnostic algorithm that incorporates ESR, CRP, and clinical findings can be used to improve the recognition of osteomyelitis in diabetic patients 4.