SLR - August 2022 - Riya Vyas, DPM
Reference: Spellberg B, Aggrey G, Brennan MB, et al. Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open. 2022;5(5):e2211321. doi:10.1001/jamanetworkopen.2022.11321Level of evidence: Level III – systematic review
Scientific Literature Review
Reviewed by: Riya Vyas, DPM
Residency Program: Mercy Health – St. Vincent Medical Center
Podiatric Relevance: The authors used the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. The aim of this study was to establish clear clinical recommendations for pyogenic osteomyelitis and its management by reducing the discrepancy between online recommendations and quality of evidence.
Methods: The WikiGuidelines group formed on Twitter consists of 63 participants consisting of physicians, pharmacists, and microbiologists specializing in internal medicine, pediatrics, infectious diseases to name a few. Seven questions were answered about diagnosis and management of pyogenic osteomyelitis. For each question, authors recruited via social media conducted their own literature review using PubMed. The participants were only allowed to give clear recommendations that were backed with one adequately powered randomized controlled trial, and at least one other prospective, controlled clinical study. When differing opinions on article interpretation or clinical practice existed among the authors, the diverging opinions were brought to light by discussing care alternatives.
Results: Participants found sufficient data to establish clear recommendations for only 2 questions: 1. Is oral antibiotic therapy for pyogenic osteomyelitis appropriate, and 2. The duration of therapy for osteomyelitis. Enough data was obtained to conclude that oral therapy is a reasonable option for OM of all types, especially in patients who are hemodynamically stable, have source control, a healthy GI tract, and have no psychosocial contraindications. The duration of therapy the authors recommend based on 2 RCTs and observational studies is a maximum of 6 weeks of therapy for hematogenous and contiguous pyogenic osteomyelitis. The following 5 out of 7 questions were addressed with clinical reviews but without high-quality data: how to diagnose osteomyelitis, management of osteomyelitis underlying pressure ulcers, appropriate timing of empirical therapy, preferred antimicrobial options to treat osteomyelitis, and role of serial biomarkers or imaging studies to evaluate treatment response.
Conclusions: WikiGuidelines provides a reliable, novel approach to creating guidelines for clinical practices by separating evidenced-based recommendations from opinions based on lower-quality data. For management of pyogenic osteomyelitis it was determined that: 1. plain x-rays incur high burden than value if routinely ordered for all patients, 2. the routine ordering of low accuracy inflammatory biomarkers should be limited, 3. oral antibiotic therapy should be increased, and 4. limiting the duration of therapy to the shortest necessary. The authors conclude that no clinical trial can apply to all patient situations, and therefore clinician judgement should not be overridden by these guidelines.