Local Antibiotic Therapy Was Not Given Enough Space

Treatment Algorithms for Chronic Osteomyelitis by Dr. med. Gerhard Walter, Dr. med. Matthias Kemmerer, Dr. med. Clemens Kappler, Prof. Dr. med. Reinhard Hoffmann in volume 14/2012

The authors deserve thanks for their review article. However, contrary to my own expectations, they dedicate only one sentence to local antibiotic treatment—namely, that the effectiveness of local antibiotic therapy has not been scientifically proven. The reference cited in support of this statement is to a study investigating systemic antibiotic therapy in the plastic surgery setting, which similarly deals with the subject in one sentence only: “Local delivery of aminoglycosides could potentially eliminate the need for systemic aminoglycosides.”

I wish to speak up in favor of adjuvant, local antibiotic therapy. If tolerated, such treatment may result in temporarily much higher local bactericidal concentrations of the active substance—ideally accompanied by a reduced risk for sub-inhibitory concentrations of active substance (1). Furthermore, local antibiotic therapy seems to be an important addendum to vacuum therapy for the purpose to the so called dead space management. Our experiences and the literature on the subject of antibiotic-coated bone marrow nails (2), their further development, and biodegradable antibiotic carriers (1, 3) give rise to hopes for an additive effect. The polymethylmethacrylate (PMMA) chains shown in the available article have not been popular for quite some time now (1, 3).

In actual fact, solid scientific proof is lacking for the therapeutic options for chronic osteomyelitis/osteitis. In my opinion, however, the cornerstones of treatment are surgical debridement, stabilization, dead space management, and systemic and adjuvant local antibiotic therapy.

DOI: 10.3238/arztebl.2012.0576a

Dr. med. Peter H. Thaller

Chirurgische Klinik und Poliklinik – Innenstadt
Klinikum der Universität München,

References

1. von Hasselbach C: Klinik und Pharmakokinetik von Kollagen – Gentamycin als adjuvante Lokaltherapie knöcherner Infektionen. Der Unfallchirurg 1989; 92: 459–70

2. Thonse R, Conway JD: Antibiotic Cement-Coated Nails for the Treatment of Infected Nonunions and Segmental Bone Defects. The Journal of Bone and Joint Surgery 2008; 90 Suppl 4: 163–74

3. Stemberger A, Grimm H, Bader F, Rahn HD, Ascherl R: Local treatment of bone and soft tissue infections with the collagen-gentamicin sponge. The European Journal of Surgery 1997; Suppl 578 Acta chirurgica: 17–26.

4. Walter G, Kemmerer M, Kappler C, Hoffmann R: Treatment algorithms of chronic osteomyelitis. Dtsch Arztebl Int 2012; 109(14): 257–64