Osteomyelitis
Osteomyelitis is an infection in bone. It is usually treated with antibiotics and sometimes surgery. A long-standing bone infection is called chronic; refractory means it persists or returns despite appropriate treatment. Some international bodies consider hyperbaric oxygen therapy (HBOT) as an additional treatment for selected refractory cases. In the UK, NICE says HBOT should not be offered for diabetic foot ulcers outside a clinical trial, and NHS England does not routinely commission it for osteomyelitis.
This page is written for adults with a bone infection that has not cleared, including people with diabetic foot osteomyelitis, their families, and the clinicians treating them.
What osteomyelitis is
Osteomyelitis is an infection in a bone. The NHS says it usually goes away when treated early with antibiotics. It can cause severe pain, swelling, warmth, redness and sometimes a high temperature. In people with diabetes and neuropathy, a foot infection may be present without marked pain.
People are more at risk if they have diabetes, especially with a foot ulcer, a previous fracture or wound, a weakened immune system, or a previous bone infection.
Chronic osteomyelitis is a long-standing or recurrent bone infection. Refractory osteomyelitis has persisted or recurred despite appropriate treatment, which may include antibiotics and surgery where indicated. International HBOT recommendations address the refractory group, with HBOT considered only as an adjunct to specialist care.
Diabetic foot infection is an important setting. NICE advises clinicians to consider osteomyelitis with a local infection, deep wound or chronic wound, even when inflammatory markers, X-rays or probe-to-bone testing are normal. If the diagnosis is uncertain after an initial X-ray, MRI may be considered. A diabetic foot ulcer and diabetic foot osteomyelitis can occur together, but they are not identical diagnoses; the guidance on HBOT for ulcers and the guidance on treating infection should be described separately.
How osteomyelitis is normally treated
Antibiotics are the main treatment. The NHS says a course usually lasts four to six weeks and, for a severe infection, may last up to twelve weeks. Surgery may be needed to drain an abscess or remove infected or damaged bone. The precise treatment and duration depend on the site, organism, severity, blood supply and surgical findings.
For diabetic foot infection, NICE says to start antibiotics as soon as possible and use a specialist plan for suspected osteomyelitis. Limb-threatening or life-threatening problems need immediate referral to acute services. Other active diabetic foot problems should be referred to the multidisciplinary foot care or foot protection service within one working day.
The 2023 IWGDF/IDSA guideline suggests considering removal of infected bone with antibiotics in selected cases. It suggests six weeks of antibiotics when bone is not resected or amputated, and up to three weeks after minor amputation if the bone margin culture is positive. Some carefully selected forefoot infections can be treated without surgery. Your treating team decides which pathway applies.
Care is led by orthopaedic, infection or diabetic foot specialists.
HBOT never replaces antibiotics, drainage, debridement, pressure relief, vascular assessment or other treatment your team recommends. Where it is considered, it is an adjunct to a documented specialist plan.
What UK guidance says
NICE guideline NG19 says not to offer HBOT to treat diabetic foot ulcers unless as part of a clinical trial. Where a bone infection occurs beneath a diabetic foot ulcer, this ulcer recommendation is directly relevant. It is a recommendation about ulcer treatment; it should not be presented as a separate NICE trial-only recommendation for every case of osteomyelitis.
For refractory osteomyelitis outside a diabetic foot ulcer, we have not identified a NICE recommendation supporting HBOT. The absence of a recommendation is not proof of benefit or proof of no benefit.
NHS England’s current national specialised HBOT service specification provides for decompression illness and gas embolism. It lists diabetic lower limb ulceration among indications that are not routinely commissioned; osteomyelitis is not a routinely commissioned indication under this service. “Not routinely commissioned” is more precise than saying NHS treatment can never be funded in an exceptional case.
That is the current UK framework and Heal & Go₂ works within it.
How the international picture differs
The European Committee for Hyperbaric Medicine suggests HBOT for chronic refractory osteomyelitis as a type 2 recommendation based on level C evidence.
The Undersea and Hyperbaric Medical Society recognises refractory osteomyelitis among its accepted indications. These professional recommendations do not establish that HBOT is effective in an individual case or change UK commissioning.
The key word is refractory: persistent or recurrent infection despite appropriate conventional treatment. Surgery is considered when indicated, but is not suitable or necessary for every patient. HBOT is never a substitute for adequate antibiotics and source control.
For diabetes-related foot infection, the 2023 IWGDF/IDSA guideline conditionally suggests against HBOT as an adjunct for the sole purpose of treating infection, on low-certainty evidence. It distinguishes infection control from any separate question about ulcer healing. This makes a diabetic foot bone infection a particularly cautious assessment.
Where it is used routinely
In the United States, Medicare covers HBOT for chronic refractory osteomyelitis that is unresponsive to conventional medical and surgical management. This is a coverage decision in a different health system and does not change NHS England’s commissioning position.
Where the evidence shows possible benefit
A 2021 narrative review reported that published experience with HBOT alongside antibiotics and, where indicated, surgery was encouraging in refractory osteomyelitis. Its authors described courses often involving 20 to 40 sessions. This is not proof that HBOT caused an improvement, nor a treatment schedule or expected outcome for an individual patient.
The European consensus therefore suggests HBOT for selected refractory cases. The strength of that recommendation is limited by the quality of the evidence.
Where the evidence does not support use
The 2021 review identified no randomised trials directly testing HBOT for refractory osteomyelitis. Published case series and observational studies cannot reliably separate the effect of HBOT from antibiotics, surgery, patient selection and other care. A 2025 single-centre retrospective study reported more improvement among those who completed HBOT, but did not show a statistically significant difference in infection resolution, further surgery or amputation. It cannot establish causation.
For diabetic foot problems, NICE advises against HBOT for ulcer treatment outside a trial, while IWGDF/IDSA suggests against it solely to treat infection. These are distinct recommendations and both matter when an ulcer and osteomyelitis coexist.
HBOT has no established role in routine osteomyelitis that is responding to appropriate treatment. Further testing or a change to standard treatment should be directed by the treating specialists if infection persists.
Where the evidence is weak or absent we say so here rather than leaving it out.
How we assess whether treatment is appropriate
HBOT is not offered for osteomyelitis in general. A selected adult with genuinely refractory infection may be considered for specialist assessment, with uncertainty explained upfront.
Standard care comes first. We would need a specialist-confirmed diagnosis, evidence that appropriate treatment has been tried or considered, and a clear reason to think HBOT might add value. If you have a diabetic foot ulcer, we will explain NICE’s trial-only recommendation for treating that ulcer. If the purpose is infection control, we will also explain the IWGDF/IDSA recommendation against HBOT solely for that purpose.
Your existing team stays in charge. If you are under orthopaedic, infection, diabetes or foot care specialists, stay with them. Nothing here is a reason to change, pause or delay anything they have recommended, including antibiotics, surgery or urgent vascular care. If HBOT is considered, we work alongside them and share our assessment and treatment plan.
HBOT has risks and contraindications, including pressure-related ear injury, visual changes and other individual risks. We review relevant medicines, medical conditions and chamber safety before making a recommendation. Our safety page provides more detail.
How the assessment works. We normally require a referral and relevant records from the clinician treating the infection, including microbiology, imaging, antibiotic history, surgical assessment and, for a diabetic foot, vascular and foot-care plans where relevant.
Our Medical Director considers the diagnosis, reasons for treatment failure, evidence, safety and whether the specialist team supports an adjunctive plan. We explain why HBOT is or is not appropriate, including the evidence limits, risks, alternatives and costs, before any agreement.
HBOT is not appropriate for every patient or every bone infection. Specialist assessment may be reasonable for selected refractory cases, but an assessment is not a promise of treatment or benefit. If we do not think HBOT is appropriate, we will say so.
Common questions
Is hyperbaric oxygen available on the NHS for osteomyelitis?
HBOT for osteomyelitis is not routinely commissioned under NHS England’s national specialised service. The service covers decompression illness and gas embolism; diabetic lower limb ulceration is explicitly listed as not routinely commissioned. Ask your NHS specialist whether any research or exceptional pathway applies to your circumstances.
I have diabetes and a foot ulcer with bone infection. Can hyperbaric oxygen help?
NICE says HBOT should not be offered to treat diabetic foot ulcers outside a clinical trial. The 2023 IWGDF/IDSA guideline also suggests against HBOT solely to treat a diabetic foot infection, including bone infection. Your multidisciplinary foot team should lead treatment, including infection control, pressure relief and vascular assessment. We would explain these limits before considering any separate assessment.
Does it replace antibiotics or surgery?
No. HBOT cannot replace appropriate antibiotics, drainage, debridement or vascular care. The treating specialist team decides which of those are needed. HBOT has no established role in routine infection that is responding to treatment.
How many sessions would be involved?
Published reports often describe 20 to 40 sessions, but this is not a standard prescription or guarantee of benefit. Any proposed course, monitoring points and stopping rules would be agreed in writing with you and your treating team after assessment.
Is it safe?
It’s generally well tolerated but not without its risks, including ear pressure injury and temporary visual changes, and some people cannot receive it safely. We review your medical history and medicines, and explain individual risks before any treatment decision. See our safety page for more detail.
- Clinical and advertising approval
- Approved 24 September 2026 · Dr Anil Dasineni (own revision)
- Reviewed by
- Dr Anil Dasineni, MBBS, DNB (Emergency Medicine), MRCEM. Registered with the General Medical Council with a licence to practise.
- Last reviewed
- 1 October 2026
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Sources (10)
www.nice.org.uk/guidance/ng19, www.nhs.uk/conditions/osteomyelitis/, www.england.nhs.uk/wp-content/uploads/2018/11/Hyperbaric-oxygen-therapy-services-all-ages-Service-specification-January-2025.pdf, www.england.nhs.uk/commissioning/spec-services/npc-crg/group-d/hyperbaric-oxygen-therapy/, onlinelibrary.wiley.com/doi/full/10.1002/dmrr.3687, www.echm.org/documents/DHM%202017-Mathieu%20D-Tenth%20European%20Consensus%20Conference%20on%20Hyperbaric%20Medicine.pdf, uhms.org/resources/featured-resources/hbo-indications.html, pubmed.ncbi.nlm.nih.gov/34390634/, www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=12, pubmed.ncbi.nlm.nih.gov/39836555/
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