Treatment of bone infection is a difficult procedure. At present, the overall treatment strategy includes conservative treatment, palliative debridement, En-block resection, and amputation, but there is a lack of uniform treatment standards. A surgical operation is the usual method chosen by clinicians, but not all cases require surgical debridement , and many infections can be effectively treated with oral therapy [8-10]. Hamed  reported that intravenous antibiotics (six weeks) and oral suppression therapy were administered for cases of PJI infection, with reliable clinical efficacy. Research showed that drug therapy alone had an average success rate of 71.1%, while surgical treatment alone had an average success rate of 88.9% . Systemic intravenous antibiotics after debridement can achieve a rapid reduction of the bacterial load at the site of infection . Therefore, clinicians are more inclined to use surgical treatment combined with antibiotic treatment to arrest the infection.
According to previous studies, optimal treatment of acute hematogenous osteomyelitis involves intravenous antibiotics for several weeks, and then oral antibiotics until the symptoms and signs are alleviated [14, 15]. However, for chronic bone infection, debridement is often the first choice. Although research has shown that oral and parenteral therapies achieve similar success rates , clinicians are accustomed to considering the use of intravenous antibiotics during hospital stay [16, 17], followed by oral antibiotics for several weeks. It has been reported that intravenous antibiotics for less than one week have no significant effect on prognosis [18-20]. However, only limited data is available comparing intravenous antibiotics and oral antibiotics or concerning proper treatment durations. We applied debridement plus systemic antibiotic treatment. Most patients (80.6%）were treated with intravenous antibiotics for only two weeks, although long-term antibiotic use has achieved good results in previous reports. Our results showed the recurrence rate of the IV group was not significantly different from the other two groups and the overall infection control rate was 83.6%. The infection control rate is comparable to that of previous reports, providing support for the treatment of these patients with short-term systemic antibiotic regimens following debridement.
Multiple and refractory bacteria are common in bone infections, especially for chronic infections, so combined antibiotic treatments are commonly applied in the clinics. The most common oral combination drug is rifampicin, which has a bactericidal effect on multiple gram-positive and gram-negative bacteria . Rifampicin can achieve high intracellular levels and is capable of penetrating bacterial biofilm [21, 22]. However, it is not advisable to only apply rifampicin for anti-infection treatment, because it can quickly lead to resistance . Thus, rifampicin should be started after bacterial load reduction by surgery and when the wound is dry [23, 24]. In this study, 307 (48.0%) patients were infected with Staphylococcus aureus and 56 (8.8%) with Pseudomonas aeruginosa, accounting for more than 50% of the isolated bacteria, and so levofloxacin was applied more often in our clinic. Levofloxacin alone was unable to eradicate methicillin-susceptible S. aureus [25, 26]. The classic antibiotic combination for bone infections caused by Staphylococcus aureus and P. aeruginosa is levofloxacin plus rifampicin.
It is difficult to assess how long it will take for an infection to clear the following treatment of bone infection. Urania Rappo  evaluated the efficacy of infection after six weeks of treatment. Daver NG  indicated that the infection is apparently cured if it does not recur within six months. We evaluated infection control at six months after the operation. Although this may miss some cases of recurrence, our statistical analysis shows that recurrence occurs within two months in most cases.
Although rifampicin is rarely used alone in the treatment of bone infections, when used in combination with other antibiotics, rifampicin can increase the treatment outcomes of other antibiotics. Rifampicin diffuses very well within bone tissue and bacterial biofilms  and is a valuable treatment option. However, rifampicin often elicits a hepatotoxic response and gastroenteropathy. Our results indicated that the ALT abnormality rate of the Rifampicin group is significantly higher, suggesting that postoperative combinations including rifampicin may lead to liver damage. In addition, Sahoko  reported that rifampicin can cause acute renal damage. Our results show that the overall complication was acceptable in the three groups. The recurrence rate of the IV group was not significantly different from that of the other two groups. Meanwhile, the Oral group and Rifampicin group had higher ALT and proteinuria rates, and the abnormality was probably caused by the additional oral therapies. Although proteinuria the Rifampicin group was the highest, the creatinine positive rate was not statistically significantly different, suggesting that the additional rifampicin therapies may cause early or mild renal damage.
There are many highlights in this article including the large sample size and its use of standard techniques. However, there are several drawbacks. First, although our result showed that there was no significant statistical difference in the general data, including the type of bacterial infection and fixation method, the heterogeneity within the cohort may have affected the results. Second, the abnormality of ALT and urinary protein suggested possible liver and renal damage, but the extent of the damage was not determined. Third, recurrence is common in bone infection, and the long-term recurrence rate for patients (after the six months follow-up) is unknown.