Antibiotics Often Unnecessary for Sacral Pressure Ulcers Complicated by Osteomyelitis
Randomized controlled trials are critically needed in this space to improve evidenced-based decision-making, including around the effect of biopsy on diagnosis and treatment decisions.
A systematic literature review, published in Clinical Infectious Diseases, found no evidence supporting a benefit to antibacterial therapy for osteomyelitis in patients with stage IV sacral pressure ulcers without concomitant surgical debridement and wound coverage.
A search for "pelvic osteomyelitis" or "decubitus AND osteomyelitis" or "sacral osteomyelitis" from 1975 to the present using PubMed, Google Scholar, and Web of Science search engines produces 30 manuscripts. Of these, 5 were excluded because they did not specifically address pelvic/sacral osteomyelitis or focused on chronic osteomyelitis as a general entity. Another 5 that described the role of hemicorpectomy and hemipelvectomy for intractable pressure ulcers were also excluded.
Review of the remaining 20 published manuscripts suggested that osteomyelitis may actually be uncommon in individuals with chronic stage IV sacral pressure ulcers, and that bone biopsy provides the most accurate diagnosis compared with other diagnostic tests and imaging. The data also did not support the theories that osteomyelitis affects the risk for recurrence after wound coverage, nor the practice of administrating antibiotics to treat osteomyelitis for more than 6 weeks, or the use of intravenous rather than oral antibiotics.
According to investigators, "[t]he goal of therapy should be local wound care and assessment for the potential of wound closure." Appropriate antibiotic therapy is only reasonable, concluded investigators, "[i]f the wound can be closed and osteomyelitis is present on bone biopsy." Further, they acknowledge that without consideration and mitigation of the often-complex psychosocial issues that also accompany medical comorbidities in these patients, complete healing is unlikely. Among several other recommendations, investigators stress that "[r]andomized-controlled trials are critically needed in this space to improve evidenced-based decision-making, including around the impact of biopsy on diagnosis and treatment decisions, and the breadth and duration of antimicrobial therapy," and that clinicians must be ready to adapt in the face of new evidence.
Wong D, Holtom P, Spellberg B. Osteomyelitis complicating sacral pressure ulcers: whether or not to treat with antibiotic therapy [published online July 7, 2018]. Clin Infect Dis. doi: 10.1093/cid/ciy559