SPINE Volume 33, Number 10, pp E297E304

2008, Lippincott Williams & Wilkins

Fluoroquinolones Versus -Lactam Based Regimens for

the Treatment of Osteomyelitis
A Meta-Analysis of Randomized Controlled Trials
Eirinaios M. Karamanis, MD,* Dimitrios K. Matthaiou, MD,* Lampros I. Moraitis,
and Matthew E. Falagas, MD, MSc, DSc*

Study Design. A meta-analysis of randomized control

trials.
Objective. To compare fluoroquinolones to -lactams
for the treatment of osteomyelitis.
Summary of Background Data. Treatment of osteomyelitis remains a real challenge in medicine necessitating
the use of broad-spectrum antibiotics, because of the
variety of the pathogens causing the infection and the fact
that the infected bone may become necrotic and avascular, preventing systemic antibiotics from adequately penetrating to the infection site.
Methods. A literature search was performed by 2 reviewers independently (PubMed database and the Cochrane Central Register of Controlled Trials).
Results. We identified 7 studies eligible for inclusion in
our meta-analysis; ciprofloxacin, ofloxacin, and pefloxacin were used in 3, 3, and 1 study, respectively, while
various -lactams (mainly in the intravenous form) were
used as comparators. There was no difference in treatment success for osteomyelitis between fluoroquinolones and -lactams [194 patients, fixed effect model (FEM),
odds ratio (OR) 0.99, 95% confidence interval (CI) 0.51
1.91], bacteriological success (201 isolates, FEM, OR 0.88,
95% CI 0.451.70), superinfections (173 patients, FEM,
OR 1.75, 95% CI 0.63 4.90), relapses (153 patients, FEM,
OR 1.23, 95% CI 0.46 3.31), or adverse events (170
patients, FEM, OR 0.47, 95% CI 0.211.06).
Conclusion. Fluoroquinolones are as effective as -lactams for the treatment of osteomyelitis and can be considered as a useful alternative in the physicians armamentarium. The value of fluoroquinolones for the treatment of
osteomyelitis lies in the fact that they can be administered in
an outpatient setting. However, they should be used with
caution, so as to preserve their activity against increasingly
resistant bacteria.
Key words: ciprofloxacin, ofloxacin, pefloxacin, imipenem, diabetic foot. Spine 2008;33:E297E304

Osteomyelitis remains a difficult to cure clinical entity,

having a devastating impact on patients quality of life
and sense of well being, despite the advent of many new
From the *Alfa Institute of Biomedical Sciences (AIBS), Athens,
Greece; National Technological University of Athens, Greece; Department of Medicine, Henry Dunant Hospital, Athens, Greece; Department of Medicine, Tufts University School of Medicine, Boston,
MA.
Acknowledgment date: November 20, 2007. Revision date: December
12, 2007. Acceptance date: December 18, 2007.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Matthew . Falagas,
MD, MSc, DSc, Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 151 23 Marousi, Greece; E-mail: m.falagas@aibs.gr

antibiotics. The cause for the difficulty in the treatment of

osteomyelitis is that infected bone may become necrotic
and avascular and thus systemic antibiotics cannot adequately penetrate to the infection site. Gram-positive
bacteria, mainly Staphylococcus aureus and streptococci, as well as gram-negative pathogens, mainly
Pseudomonas aeruginosa and Enterobacteriaceae are
commonly responsible for osteomyelitis.1 4 Thus, the
use of broad-spectrum antibiotics is warranted for the
treatment of osteomyelitis.
Until the advent of fluoroquinolones, recommended
regimens for the treatment of osteomyelitis included
cephalosporins, alone or in combination with aminoglycosides, carbapenems, antipseudomonal penicillins
along with -lactamase inhibitors, vancomycin, and trimethoprim/sulfonamide combinations. The above
agents have a broad spectrum of antimicrobial activity
coupled with sufficient penetration in bone tissue, but
many of them are administered only intravenously, a fact
that renders them inconvenient for the long duration
treatment of osteomyelitis. They are also usually administered in combination regimens, leading to higher toxicity and cost of therapy.
Fluoroquinolones may alternatively be used for the
treatment of osteomyelitis, because they have a broad
antimicrobial spectrum covering a wide range of grampositive and gram-negative bacteria. In addition, they
may be administered either intravenously or orally,
which is a more comfortable and less annoying route for
patients. Furthermore, fluoroquinolones have good oral
bioavailability and satisfactory penetration in bone and
adjacent soft tissue.5,6
For all the aforementioned reasons, fluoroquinolones
seem an appealing option for the treatment of bone and
joint infections and especially for the treatment of osteomyelitis. To examine the above hypothesis, we conducted a
meta-analysis of randomized control trials comparing fluoroquinolones to -lactams and other conventional agents
for treatment of osteomyelitis.
Methods
Data Sources
Two reviewers (D.K.M. and E.M.K.) independently performed
the literature search. The studies for our meta-analysis were
retrieved from a search of the PubMed database and the Cochrane Central Register of Controlled Trials. Search terms included the terms osteomyelitis, quinolones, -lactams,
and the individual names of fluoroquinolones. Any disagreement between the 2 reviewers regarding the evaluability of a
E297

E298 Spine Volume 33 Number 10 2008

study was resolved by consensus in meetings that involved all
authors.

Study Selection Criteria

The identified relevant studies were further evaluated. A study
was considered eligible for inclusion in our meta-analysis if: (1)
it was a randomized controlled trial comparing fluoroquinolones with other conventional agents for the treatment of patients
with osteomyelitis, (2) it reported data regarding the clinical
success of the treatment, the bacteriological success, the relapses, the superinfections and/or the patients with adverse
events, and (3) if it included more than 10 patients in each
treatment arm.

Validity Assessment
A review of the quality of each RCT included in our metaanalysis was performed by using the Jadad score, which examines whether there is randomization, blinding, and information
on withdrawals from the study, and evaluates the appropriateness of randomization and blinding, if present.7,8 One point
was awarded for the presence of each of the former 3 criteria,
whereas the latter 2 criteria could be awarded the values of 1
(inappropriate), 0 (no data), and 1 (appropriate). Thus, the
maximum score for a study was 5; a score higher than 2 points
denotes a good quality RCT according to this methodology.
The reviewers calculated the Jadad score of each study independently.

Data Extraction
Two reviewers (D.K.M. and E.M.K.) independently extracted
and tabulated the data from the selected studies. The data extracted from each study included the author names and year of
publication, the population of interest, the number of patients,
the type of therapeutic regimens used, the adjunctive treatments used (if any), the location and extend of focus of osteomyelitis, the duration of therapy and of the follow-up, as well
as treatment success, bacteriological success, relapses, superinfections, and patients with adverse events. For studies not focusing exclusively on patients with osteomyelitis, we extracted
the data which were reported particularly for the subset of
patients with such infections.

Definition of Outcomes
Patients were considered to have osteomyelitis, when the diagnosis was confirmed by bone biopsy or alternatively was established by appropriate findings in at least 2 of the following
diagnostic methods: (a) clinical examination, (b) conventional
radiography, (c) bone scanning, and (d) computed tomography
or magnetic resonance imaging. The primary outcome of our
meta-analysis was defined as treatment success of each regimen. Cure was defined as resolution of all signs and symptoms
of active infection at the end of follow-up period. The secondary outcomes of our meta-analysis included bacteriological
success, relapses, superinfections, and number of patients experiencing adverse events due to the administered regimens.
Bacteriological success was defined as absence of all causative
organisms from the culture at the end of follow-up. Superinfection was defined as isolation of new pathogens from the site of
the infected bone during the course of therapy. Relapse was
defined as reappearance of the causative pathogen during follow-up, after prior clinical signs or microbiological data of
eradication.

Statistical Analysis
Statistical analyses were performed using the S-Plus 6.1 software (Insightful Corp., Seattle, WA). The heterogeneity between studies was assessed by using the 2-test; a P value less
than 0.10 was defined to denote the presence of statistically
significant heterogeneity between studies. Bias of small studies
was assessed by the funnel plot method using the Egger test.
Pooled odds ratios and 95% confidence intervals (CIs) for all
primary and secondary outcomes were calculated by using
both the Mantel-Haenszel fixed-effect model 9 and the
DerSimonian-Laird random-effects model.10 For all analyses,
results obtained with the fixed-effect model (FEM) are presented if there was no heterogeneity between studies; otherwise, results from the random effects model are presented. The
reported outcomes of the analyzed studies were weighted by
the inverse of their variance with the fixed-effect model.

Results
Study Selection Process
In Figure 1, we present a flow diagram depicting the
various steps of the study selection process. We identified
287 potentially relevant studies that included patients
with osteomyelitis, exclusively or as a subset of the whole
study population, who were treated with fluoroquinolones or other conventional agents. From those, 220 studies were excluded because they were case reports, reviews, animal or laboratory studies, imaging studies,
case series, or retrospective studies. Fifty-six studies were
further excluded because they constituted noncomparative studies. Also, 3 studies were excluded because they
were not randomized controlled trials and another study
was excluded because it included a small number of patients. The remaining 7 studies met the inclusion criteria
and were evaluated further.1117
Study Characteristics
In Table 1, we present the characteristics (patient population, administered drugs, duration of treatment, and
follow-up) of the RCTs included in our meta-analysis.
Patients in the first treatment arm of all RCTS received
fluoroquinolones. The fluoroquinolones used were ciprofloxacin in 3 studies, which were the older ones, performed,14,16,17 ofloxacin in 3 studies, which were the
newer ones,1113 and pefloxacin in 1 study.15 Fluoroquinolones were administered exclusively orally in 4 out of
7 RCTs,13,14,16,17 whereas in the other 3 RCTs, fluoroquinolones were administered parenterally and subsequently orally.11,12,15 Patients in the second treatment arm
received -lactams. In 5 out of 7 RCTs, -lactams were
administered exclusively via the parenteric route.11,1316 In
one RCT, -lactams were administered intravenously and
subsequently orally,12 whereas in one RCT, the route of
administration is not clear.17 With the exception of the
study by Gomis et al12 and by definition for the study by
Lipsky et al,12 no specific data were reported regarding the
location and extend of focus of osteomyelitis. Furthermore,
no data regarding surgical procedures undertaken after the
enrollment of patients in the trials were reported.

Fluoroquinolones for Osteomyelitis Karamanis et al E299

Figure 1. Flow diagram of the

study selection procedure.

Treatment Success
In Table 2, we present data regarding the primary and
secondary outcomes. Data about treatment success were
provided in all 7 RCTs included in our meta-analysis.1117
There was no difference in treatment success between fluoroquinolones and -lactams [194 patients, FEM, odds ratio
(OR) 0.99, 95% CI 0.511.91, P 0.97]. The odds
ratios for treatment success in the individual RCTs, as well
as the pooled odds ratio, are presented graphically in Figure
2(A).

Superinfections
Data about superinfections were reported in 6 out of 7
RCTs.11,1317 Although superinfections were more frequent in patients receiving fluoroquinolones, there was
no statistically significant difference in the superinfections between fluoroquinolones and -lactams (173 patients, FEM, OR 1.75, 95% CI 0.63 4.90, P
0.28). The odds ratios for superinfections in the individual RCTs, as well as the pooled odds ratio, are presented
in Figure 3(A).

Bacteriologic Success
Data about bacteriological success of fluoroquinolones versus -lactams were provided in 6 out of 7 RCTs.11,1317
There was no difference in bacteriological success between
the 2 compared treatments (201 isolates, FEM, OR 0.88,
95% CI 0.451.70, P 0.71). The odds ratios for bacteriologic success in the individual RCTs, as well as the
pooled odds ratio, are presented in Figure 2(B).

Relapses
Data about relapses were reported in 5 out of 7 RCTs.1317
The follow-up period for the evaluation of relapses ranged
from 6 to 18 months. There was no difference in relapses
between fluoroquinolones and -lactams (153 patients,
FEM, OR 1.23, 95% CI 0.46 3.31, P 0.68). The
odds ratios for relapses in the individual RCTs, as well as
the pooled odds ratio, are presented in Figure 3(B).

E300 Spine Volume 33 Number 10 2008

Table 1. Main Characteristics of the Included Randomized Controlled Trials

Author (Year)

Study Design

Population

Gomis et al,
199911

Open-label
RCT

Patients with chronic osteomyelitis.

Neutropenic patients and
patients with uncontrolled
diabetes were excluded

Lipsky et al,
199712

Open-label
multicenter
RCT

Gentry and
RodriguezGomez,
199113

Fluoroquinolone
Regimen

Other Regimen

Adjunctive Treatments

Ofloxacin 400 mg
p.o. q12h (if
not possible it
was
administered
i.v.)

Imipenem/cilastatin 500 mg
i.v. q6h

Patients with osteomyelitis due to

diabetic foot infections. Patients
with evidence of OM were not
to be enrolled unless all of the
infected bone was to be
removed soon after enrollment

Ofloxacin 400 mg
i.v. q12h
changed to
p.o. when
appropriate

Ampicillin 12 g/sulbactam
0.51 g i.v. q6h changed
to amoxicillin 500 mg/
clavulanic 125 mg p.o.
q8h when appropriate

Open-label
RCT

Patients with chronic biopsyconfirmed osteomyelitis. Patients

with prosthetic material were
not enrolled

Ofloxacin 400 mg
p.o. q12h

Cefazoline 1 g i.v. q8h or

ceftazidime 2 g i.v. q12h
(q8h for Pseudomonas
aeruginosa infections)

Gentry and
Rodriguez,
199014

Open-label
RCT

Ciprofloxacin 750
mg p.o. q12h

Giamarellou
et al,
198915

Open-label
RCT

Patients with acute or chronic

biopsy-confirmed osteomyelitis.
Before enrollment all infections
had been surgically debrided
and all foreign metallic material
was removed
Patients with chronic osteomyelitis
in exacerbation

Broad spectrum
cephalosporin i.v.
(usually ceftazidime) or
nafcillin-aminoglycoside
combination (usually
amikacin)
Ceftazidime 2g i.v. q8h or
1g i.m. q8h

Clindamycin in the first

group when there was a
suspicion or isolation of
anaerobic pathogens. No
data reported about the
no. of patients who
received clindamycin
Metronidazole to ofloxacin
and gentamicin,
trimethoprimsulfamethoxazole or
another agent to
aminopenicillin for better
gram-negative coverage.
No data regarding the
no. of patients who
received adjunctive
antibiotics
For the cefazolin group,
cloxacillin sodium was
administered following
cefazoline therapy for
chronic suppression of
Staphylococcus aureus
OM in elderly subjects
with histories of
relapses. 4 out of 14
patients received
cloxacillin sodium in this
group
NA

Snydman
et al,
198916

Open-label
RCT

Patients with acute and chronic

osteomyelitis

Greenberg
et al,
198717

Open-label
RCT

Patients with chronic osteomyelitis

Pefloxacin 400
mg i.v. or p.o.
q8h to q12h,
as well as i.v.
followed by
p.o.
Ciprofloxacin 750
mg p.o. q12h
Ciprofloxacin 750
mg p.o. q12h

NA

Alternative parenteral
antimicrobial therapy
with -lactams

NA

Another appropriate
antimicrobial therapy

NA

RCT indicates randomized controlled trial; OM, osteomyelitis; NA, not applicable; p.o, per os; i.v, intravenously; q12h, every 12 h; q8h, every 8 h; q6h, every 6 h.
*n 7 out of 8 cases pefloxacin was given for 180 d.
-Lactams, aminoglycosides, vancomycin, imipenem, clindamycin, trimethoprim/sulfamethoxazole.

Patients With Adverse Events

Data about patients with adverse events were provided
in 5 out of 7 RCTs.11,1314,16 17 There was no difference
in the number of patients experiencing adverse events
between fluoroquinolones and -lactams, although there
was a trend in favor of treatment with quinolones (170
patients, FEM, OR 0.47, 95% CI 0.211.06, P
0.07). The odds ratios for patients with adverse events in
the individual RCTs, as well as the pooled odds ratio, are
presented in Figure 3(C).

Discussion
The main finding of our meta-analysis is that fluoroquinolones were as effective as -lactams regarding the primary
outcome of treatment success for patients with osteomyelitis. Also, no difference was found between the 2 treatments
in the analyses of secondary outcomes, namely, bacteriological success, superinfections, relapses, and patients with
adverse events. However, it should be noted that in 4 of the
7 included studies fluoroquinolones were administered

Fluoroquinolones for Osteomyelitis Karamanis et al E301

Table 1. Continued
Enrolled
Patients

Intention to Treat Patients

32

21

108

21

NA

42

33 [2/19 (11%) patients and 1/14 (7%)

had diabetes in the 2 arms
respectively]

NA

67

59 [1/31 (3%) patients and 4/28 (14%)

had diabetes in the 2 arms
respectively]

NA

103

Location and Extend of Focus of OM

First group: 8 cases with contiguous OM, 4
post-traumatic, 2 postsurgical, 2 OM of
the foot in patients with DM Second
group: 6 cases with contiguous OM, 4
post-traumatic, 3 postsurgical, 2 OM of
the foot in patients with DM, 1
associated with prosthetic device
Lower extremities

The 2 groups were comparable with

respect to proportion of patients with
chronic OM, proportion with prostheses,
and location of OM
NA

Follow-up
Period

Quality
Assessment

3045 d

6 mo

9 d vs. 7 d i.v. and

12 d vs. 13 d p.o.

NA

54 d vs. 30 d

18 mo

56 d vs. 47 d

12 mo

15

46 mo* vs. 68
wk

12 mo

29

21

72 d vs. 44 d

NA

30

30 [One patient with metal appliance

at site of infection in the
ciprofloxacin group. One
immunosuppressed patient (renal
transplantation) in the comparator
group]

56 d vs. 44 d

Up to 13 mo

orally while the comparator -lactam agents were administered intravenously. Taking under consideration the fact
that fluoroquinolones exhibit high bioavailability when administered orally, fluoroquinolones appear as a valid alternative for initiation or continuation of the long-term treatment
required for osteomyelitis allowing better compliance.
To our knowledge, there has been only one relevant
meta-analysis, performed by Stengel et al,18 in which
several types of antibiotic therapies were examined for
the treatment of both bone and joint infections. In the
subanalysis of fluoroquinolones versus nonfluoroquinolone control regimens, the results were similar to the
ones obtained in our meta-analysis, despite the fact that

Mean Duration of
Therapy

the meta-analysis by Stengel et al included studies with a

broader set of infections and administered antimicrobials and the primary outcome included patients who were
either cured or improved at the end of treatment.
Fluoroquinolones have high oral bioavailability ranging from 63% to 69% for ciprofloxacin to more than
95% for ofloxacin and pefloxacin in healthy subjects.
The volume of distribution of fluoroquinolones is greater
than total body water, meaning that fluoroquinolones
tend to concentrate in tissues. Concentrations in bone
were 30% to 80% of serum concentrations for ciprofloxacin and ofloxacin.6 Also, superior tissue penetration
of fluoroquinolones compared to other agents is retained

E302 Spine Volume 33 Number 10 2008

Table 2. Primary and Secondary Outcomes of the Analyzed RCTs

Author (Year)
Gomis et al, 199911
Lipsky et al, 199712
Gentry and RodriguezGomez, 199113
Gentry and Rodriguez,
199014
Giamarellou et al, 198915
Snydman et al, 198916
Greenberg et al, 198717

Treatment Success

Bacteriological Success

Superinfections

Relapses

Patients With Adverse

Events

10/11 (90.1)
6/16 (37.5)
14/19 (73.7)

7/10 (70)
1/4 (25)
12/14 (85.7)

10/10 (100)
NA
12/20 (60)

8/10 (80)
NA
13/20 (65)

0/10 (0)
NA
1/19 (5.3)

1/10 (10)
NA
1/14 (7.1)

NA
NA
3/19 (15.8)

NA
NA
1/14 (7.1)

0/16 (0)
NA
7/19 (36.8)

3/16 (18.8)
NA
4/14 (28.6)

24/31 (77.4)

22/28 (78.6)

33/40 (82.5)

34/40 (85)

4/31 (12.9)

2/28 (7.1)

6/31 (19.4)

5/28 (17.9)

1/31 (3.2)

4/28 (14.3)

7/8 (87.5)
7/10 (70)
7/14 (50)

5/7 (71.4)
7/11 (63.6)
8/11 (72.7)

7/8 (87.5)
7/10 (70)
8/14 (57.1)

0/8 (0)
3/10 (30)
1/14 (7.1)

0/7 (0)
0/11 (0)
0/11 (0)

1/8 (12.5)
0/10 (0)
0/14 (0)

1/7 (14.3)
0/11 (0)
0/11 (0)

NA
3/10 (30)
2/14 (14.3)

NA
5/11 (45.5)
4/11 (36.4)

Values inside parentheses indicate percentages.

NA indicates not available.

Figure 2. Odds ratios of treatment success, and bacteriological success, for studies comparing quinolones with -lactams
for the treatment of osteomyelitis; (A) treatment success, (B)
bacteriological success (Vertical
line no difference point between the 2 regimens. Square
odds ratio; the size of each
square denotes the proportion of
information given by each trial.
Diamond pooled odds ratio for
all RCTs. Horizontal lines 95%
CI).

6/7 (85.7)
7/11 (63.6)
9/11 (81.8)

Fluoroquinolones for Osteomyelitis Karamanis et al E303

Figure 3. Odds ratios of (A) superinfections, (B) relapses, and (C) patients with adverse events for studies comparing quinolones with
-lactams for the treatment of osteomyelitis. (Vertical line no difference point between the 2 regimens. Square odds ratio; the size
of each square denotes the proportion of information given by each trial. Diamond pooled odds ratio for all RCTs. Horizontal lines
95% CI).

even in environments with low pH, such as it is frequently encountered in sites of infection.19 However,
caution is advised in the elderly or in individuals with
renal failure or liver disease, in whom the peak serum
concentrations rise accordingly.6
The aforementioned properties of fluoroquinolones
could be considered as potential advantages over other
agents, which are expected to result in increased efficacy
in clinical practice. Nevertheless, in our meta-analysis,
there was no difference in efficacy between fluoroquinolones and -lactams for the treatment of osteomyelitis.
This finding may be appointed to the inherent characteristics of the osteomyelitis pathophysiology. Specifically,
active osteomyelitis lesions are surrounded by necrotic
tissues and debris and have poor vascular supply, thus
preventing adequate distribution of the antimicrobial
drugs in the site, as well as the adequacy of the host
inflammatory response. Also, since osteomyelitis frequently coexists with diabetes mellitus, diabetic microangiopathy could further hamper fluoroquinolone
penetration in the inflamed tissues.
It should be mentioned though, that fluoroquinolones
are one of the few oral agents available for satisfactory
coverage of the gram-negative pathogens that are frequently a cause of osteomyelitis. Moreover, fluoroquinolones initially exhibited substantial antistaphylococcal

activity, but resistance to these agents has greatly increased in parallel with the rise in the prevalence of methicillin-resistant Staphylococcus aureus. So, for empirical therapy, fluoroquinolones should be better used in
combination with an agent with sufficient activity
against gram-positive pathogens. Nevertheless, as the
findings of our study show, the value of fluoroquinolones
for the treatment of osteomyelitis lies in the option that
they offer for treatment in an outpatient setting, without
the cost of inferior treatment outcomes nor an increased
rate of adverse events.
There are certain limitations though that should be
taken under consideration in our meta-analysis. First,
the total number of patients included in our metaanalysis is rather small to allow for true differences between compared treatments to be shown. Second, the
included studies were conducted more than 15 years ago,
most of them in a time span of 5 years between 1987 and
1991. Since then, trends of susceptibility of the pathogens to the examined agents may have changed considerably, so it is arguable if the results of these studies
could be applied in current clinical practice. Third, the
quality assessment of the included studies yielded a score
of 2, which equals to the cut-off point for considering
them as good quality RCTs. It should be also emphasized
that factors such as acuity of osteomyelitis, host immu-

E304 Spine Volume 33 Number 10 2008

nocompetency, adjunctive treatment and location and

extend of focus of osteomyelitis may considerably influence the outcome of osteomyelitis. With the exception of
acuity of infection, reported data regarding these factors were
scarce in the included studies. However, the methodology of
randomization helps decrease the misbalance of the aforementioned and other confounders between the compared treatment groups. Thus, the comparative outcomes should not
have been influenced by the presence of these factors, although
such data would be useful to be reported and taken under
consideration in the interpretation and generalizibility of the
findings of the meta-analysis.
In conclusion, fluoroquinolones proved as effective as
-lactams for the treatment of osteomyelitis, and thus could
be considered as a useful alternative in the physicians armamentarium, especially for the oral treatment of osteomyelitis in an outpatient setting. However, they should be used
with caution and according to the resistance patterns of the
pathogens in each setting, so as to preserve their potency
against increasingly resistant bacteria.
Key Points
A literature search was performed to identify randomized control trials comparing fluoroquinolones
to -lactams for the treatment of osteomyelitis.
Seven eligible trials were included in our metaanalysis.
There was no difference in treatment success,
bacteriological success, superinfections, relapses,
or adverse events between the compared regimens.

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