SLR - April 2023 - Andrew J Aldstadt, DPM PGY-1
Title: Do Anti-Biofilm Antibiotics Have a Place in the Treatment of Diabetic Foot Osteomyelitis?Reference: Senneville E, Gachet B, Blondiaux N, Robineau O. Do Anti-Biofilm Antibiotics Have a Place in the Treatment of Diabetic Foot Osteomyelitis? Antibiotics (Basel). 2023;12(2):317. Published 2023 Feb 3. doi:10.3390/antibiotics12020317
Level of Evidence: V
Scientific Literature Review
Reviewed By: Andrew J Aldstadt, DPM PGY-1
Residency Program: Mercy Health – St. Rita’s Medical Center, Lima, Ohio
Podiatric Relevance: This article aims to summarize data on whether using an anti-biofilm antibiotic (namely, rifampicin and/or fluoroquinolones) has a verifiable effect on diabetic foot osteomyelitis healing and treatment.
Methods: The authors looked at current literature and data concerning diabetic foot osteomyelitis (DFO), whether there was presence of a biofilm, and outcomes with using antibiotics, such as rifampicin and levofloxacin.
Results: The role of anti-biofilm antibiotics was found to have been studied well in diabetic ulcerations but not so much in osteomyelitis. Surgical excision of the infected bone was the most important guiding factor as this action potentially removed the biofilm. Antibiotics with good bone penetration were found to be best suited to anti-biofilm activity. These were narrowed down to rifampicin and levofloxacin. Levofloxacin was the most widely used of these antibiotics for osteomyelitis due to staph. The article presented a study by Wilson et al. showing lower event rates (i.e., amputations) with the use of rifampicin (26.9%) than for a group treated without it (37.2%; p = 0.04).
Conclusions: The article aimed to find out if using an anti-biofilm antibiotic to treat diabetic foot osteomyelitis. It found scant evidence to support, only citing two studies, one of which was over 20 years old. The initial question asked is a valid one: can anti-biofilm antibiotics prevent amputations? The study did not go into much detail on what to use outside of rifampicin, or if the patient is allergic, what to use instead. It also goes on to state that using a rifampicin/levofloxacin combination may lead to resistance. The article goes onto state that this should be initiated soon after surgery as that is when the bacterial burden should be most susceptible to antibiotic coverage. Rifampicin also has many side effects as well as a host of drug-drug interactions, something that was again mentioned but not elaborated on. The choice of using rifampicin/levofloxacin should be initiated only after a bone culture is obtained. While the article was a bit light on definitive statements for using rifampicin/levofloxacin, it does however give the clinician thoughts as to whether the biofilm/bioburden of the bone is significant enough to lead to further complications when treating diabetic osteomyelitis. The article ends with stating in vitro studies have shown promise that this combination works for the common DFO pathogens (S. aureus), but that more study needs to be done. The study states that there is an upcoming VA Intrepid study that will shed light on the subject. Hopefully, this may become another tool in the fight against diabetic foot osteomyelitis.