Infections in bone are hard to treat because there are not a lot of blood vessels in the bone. Antibiotics have a hard time penetrating bone. Chronic refractory osteomyelitis (CROM) is a bone infection that has not responded to conventional therapy such as antimicrobials and surgical debridement after a 6-week course of therapy. These chronic bone infections can occur in pediatric patients as well as adult patients, although they are often associated with other local or systemic problems. Patients who are immunosuppressed or have other co-morbidities such as diabetes are more likely to develop CROM. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5053032/
In some instances, where the bone infection has very high morbidity and mortality such as spine, skull or sternum, osteomyelitis that is not responding to treatment earlierthan six weeks may benefit from adjunctive hyperbaric oxygen therapy.
The most common presentation for CROM is in long bones after
trauma, and in diabetic foot ulcers (DFU). In the DFU, about 20% of patients
that are referred to a wound center will have osteomyelitis.
If they do not respond to a course of conventional care, which includes antimicrobial therapy and surgical debridement if possible, then patients should be referred for adjunctive hyperbaric oxygen therapy, as part of a multi-disciplinary approach including surgery is possible, and further antimicrobial therapy. https://europepmc.org/abstract/med/30035798
HBOT helps white blood cells kill bacteria, and help osteoclast clean up all the dead and infected bone. Once the infection is under control and all the dead bone is gone, new bone is laid down by osteoclasts. These processes require high levels of oxygen to function optimally. HBOT also helps antibiotics work better, and in conjunction with some antibiotics, helps eradicate the biofilms that form in many of these cases. https://link.springer.com/article/10.1007/s40138-018-0166-5
Commonly, these patients will receive 40-60 treatments to
clear the infection.