Diabetes-Related Foot Infections: Key Updates from the 2023 IWGDF/IDSA Guidelines
Foot infections remain one of the most consequential complications of diabetes, accounting for the majority of non-traumatic lower-extremity amputations worldwide. In 2023, the International Working Group on the Diabetic Foot (IWGDF) and the Infectious Diseases Society of America (IDSA) published their first combined intersociety guideline on the diagnosis and treatment of diabetes-related foot infections (DFIs). The document refines how clinicians classify infection severity, diagnose osteomyelitis, choose antibiotics, and decide when hospital admission is warranted. This article summarizes the most clinically meaningful changes for patients, caregivers, and the broader wound care team.
Diagnosis Is Still Clinical — But Biomarkers Now Play a Larger Role
The 2023 update reaffirms that the diagnosis of a soft-tissue DFI is primarily clinical, based on local or systemic signs of inflammation such as erythema, warmth, swelling, pain, or purulent discharge (Senneville et al., 2023). In equivocal cases — for example, when neuropathy blunts pain or when a wound looks indolent but is suspected to harbor infection — the guideline now explicitly endorses measuring inflammatory biomarkers. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) are all considered acceptable, with elevated values supporting the diagnosis when the bedside picture is uncertain.
Severity is graded with the IWGDF/IDSA classification, which remained unchanged in 2023 because validation studies did not justify altering the established three-tier system:
- Mild: superficial infection with limited cellulitis (≤2 cm around the wound) and no systemic involvement.
- Moderate: deeper or more extensive infection, possibly with abscess, fasciitis, septic arthritis, or osteomyelitis, but without systemic toxicity.
- Severe: any DFI accompanied by systemic inflammatory response syndrome or metabolic instability.
Osteomyelitis: A Stepwise, Multimodal Approach
Diabetes-related foot osteomyelitis (DFO) remains notoriously difficult to confirm or exclude. The 2023 guideline recommends a combined initial workup using the probe-to-bone (PTB) test, plain radiographs, and an inflammatory biomarker (ESR, CRP, or PCT). A systematic review confirmed that PTB has a pooled sensitivity of approximately 0.87 and specificity of 0.83 for detecting underlying bone infection, but interobserver agreement is only moderate and the test cannot stand alone (Lam et al., 2016).
When initial studies are non-diagnostic, magnetic resonance imaging is the preferred advanced imaging modality. The 2023 update also notes that bedside percutaneous bone biopsy is safe in experienced hands and can guide pathogen-directed antibiotic therapy — an important shift, because culture data from superficial swabs are notoriously misleading. Equally notable, the post-treatment follow-up period required to declare DFO in remission has been shortened from 12 months to 6 months, reflecting accumulated outcomes data (Senneville et al., 2023).
Antibiotics: Shorter Courses, More Precision
One of the most practice-changing updates concerns the duration of antibiotic therapy. For mild soft-tissue infections, 1 to 2 weeks of targeted oral therapy is generally sufficient. For moderate or severe soft-tissue infections that have undergone adequate surgical debridement, the panel supports antibiotic courses as short as 10 days, replacing older default regimens of several weeks. For osteomyelitis, suggested durations are up to 3 weeks after minor amputation with a positive proximal bone margin and approximately 6 weeks when no bone is resected.
A 2025 systematic review and meta-analysis of 33 studies (including 6 randomized controlled trials) found no clear benefit to extending antibiotic therapy beyond 6 weeks for DFO, supporting the move toward shorter, source-controlled regimens (Yammine et al., 2025). Reducing unnecessary antibiotic exposure lowers the risk of Clostridioides difficile colitis, adverse drug events, and antimicrobial resistance — all critical considerations in a population already burdened by polypharmacy.
When to Hospitalize
The guideline advises hospital admission for all severe DFIs and for moderate infections complicated by relevant comorbidities, particularly peripheral arterial disease (PAD), poorly controlled hyperglycemia, or inability to comply with outpatient therapy (Schaper et al., 2024). Concurrent ischemia substantially raises the risk of treatment failure and amputation, and earlier vascular assessment is now an explicit recommendation in any moderate-to-severe infection.
Clinical Takeaways
The 2023 IWGDF/IDSA guideline emphasizes three themes: standardize the clinical workup (severity grading plus biomarkers), use combined diagnostic strategies for suspected osteomyelitis (PTB + radiographs + inflammatory markers, with MRI and bone biopsy when needed), and shorten antibiotic exposure when surgical source control is achieved. Together, these changes are intended to improve healing rates, reduce amputations, and limit antimicrobial harm. Clinicians who care for people with diabetes should incorporate these updates into routine practice and ensure that suspected moderate or severe infections receive prompt multidisciplinary assessment.
References
- Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Clinical Infectious Diseases. 2023. doi:10.1093/cid/ciad527.
- Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3657.
- Lam K, van Asten SAV, Nguyen T, La Fontaine J, Lavery LA. Diagnostic accuracy of probe to bone to detect osteomyelitis in the diabetic foot: a systematic review. Clinical Infectious Diseases. 2016;63(7):944–948.
- Yammine K, Hayek F, Assi C. Impact of antibiotic duration in management of diabetic foot osteomyelitis: a systematic review and meta-analysis. Clinical Microbiology and Infection Communications. 2025. doi:10.1016/j.cmicom.2025.03.006.
- International Working Group on the Diabetic Foot. IWGDF/IDSA Infection Guideline (2023 update). Available at: iwgdfguidelines.org/infection-guideline-2023.
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