Table 2.
Summary of nonsurgical management therapies.
| Intervention | LOE | Mechanism | Clinical Outcomes | Limitations |
|---|---|---|---|---|
| Adjunct therapy to traditional antibiotic regimens | ||||
| Rifampicin | I (ongoing), III (therapeutic) | Rifampicin provides broad-spectrum antimicrobial activity with strong bone penetration and biofilm-disrupting properties, enhancing bacterial eradication in osteomyelitis. | Retrospective studies report that adding rifampicin to standard antimicrobial regimens improves DFO eradication rates. An ongoing clinical trial is investigating outcomes of adjunctive rifampicin versus placebo. | Rifampicin can be hepatotoxic; may also introduce drug interactions with concomitant use of medications metabolized by CYP3A4. |
| Antimicrobial peptides | preclinical | AMPs target bacterial membranes, causing depolarization and disruption of the proton-motive force, which impairs efflux pump function and enhances susceptibility to antibiotics. | Data on AMPs in DFO are limited to preclinical studies; in vivo models have demonstrated the ability to resensitize antibiotic-resistant bacteria by disrupting bacterial efflux mechanisms. | Evidence is limited to preclinical studies without human data; foreseeable challenges include stability, delivery, and potential cytotoxicity. |
| Topical and local therapy | ||||
| Topical oxygen therapy | IIb, IV (therapeutic) | Topical oxygen promotes phagocytosis, increases reactive oxygen species, and stimulates angiogenesis, supporting wound healing. | Case series report complete recovery in patients with diabetic foot abscesses treated with topical oxygen and drainage, with no recurrences overlong-term follow-up. A prospective study found higher healing rates in diabetic foot ulcers treated with topical oxygen compared to silver-based dressings. | Evidence focuses on abscess and ulcer healing, with limited utility for directly treating underlying DFO. Topical oxygen therapy on an additional medium for sustained delivery. |
| Medicated wound dressing | IIb, IV (therapeutic) | Silver-impregnated dressing provides sustained antimicrobial activity within the wound bed while facilitating drainage. | Case series using PWSR with drainage in diabetic foot abscesses reported complete recovery within 2–9 months and no recurrence during follow-up. | Wound dressings exhibit limited utility in treating underlying DFO, silver presents concern as potential topical irritant. |
DFO: diabetic foot osteomyelitis; Cytochrome: P450 3A4; AMP: antimicrobial peptide; PWSR: PolyMem® Wic® Silver Rope.