Antimicrobial resistance in diabetic foot osteomyelitis: diagnosis and treatment

Diabetic foot osteomyelitis remains a leading cause of non-traumatic lower-limb amputation in people with diabetes. Multidrug resistance increasingly limits empirical therapy, so diagnosis and treatment must rest on reliable microbiological sampling and local resistance epidemiology. This narrative review synthesizes current evidence on the diagnosis and antimicrobial treatment of diabetic foot osteomyelitis, with emphasis on resistance patterns. Evidence was organized into five thematic axes: diagnosis, microbiology and resistance, antimicrobial treatment, surgery and local delivery, and stewardship. Probe-to-bone testing and plain radiography remain first-line diagnostic tools, biomarkers add limited discrimination, and bone or ulcer bed biopsy guide targeted therapy with comparable remission. Staphylococcus aureus dominates the microbiology, Enterobacteriaceae are increasing, and multidrug-resistant organisms are common. Short oral regimens achieve outcomes similar to prolonged intravenous therapy, and antibiotic-loaded bone substitutes fill surgical dead space. A microbiology-driven, short-course, oral-first strategy integrated with surgery and stewardship is supported by the current literature.