Absence of Evidence or Evidence of Absence? Interpreting Bone Biopsy–Guided Therapy in Diabetic Foot Osteomyelitis

To the Editor—We thank Lagrand and colleagues for their response [1] to our editorial [2] regarding their article [3], but we would like to again clarify several points regarding the interpretation of the results. First, their 12-month remission rates (31%–39%) were significantly lower than those reported in previous prospective and randomized studies of medically treated diabetic foot osteomyelitis (DFO). The authors attribute this finding mainly to their strict definition of remission, noting that they were similar to those used by Tone et al [4] in their randomized controlled trial on the duration of antibiotic therapy, which showed a 65% remission rate at 1-year follow-up. Other factors may also have contributed to the differences in remission rates in the 2 studies, including the prevalence of diabetes-related comorbid conditions and the antibiotic regimens administered. Regarding the last point, we agree with Lagrand et al [1] that we await with interest the results of the IntrepidVA study of rifampin in DFO [5]. These contextual elements complicate direct comparison with previous studies and may influence the apparent equivalence between strategies.