0/11/2023

Updated guidelines for management of diabetes-related foot infections

Provide practical, comprehensive, evidence-based guidance for the diagnosis and treatment of foot infections in people with diabetes.

Lu-Ann Murdoch

The Infectious Diseases Society of America (IDSA) and the International Working Group on the Diabetic Foot (IWGDF) have collaborated to produce updated guidelines on the management of diabetes-related foot infections. 

The guidelines update material found in the IDSA 2012 guidelines and the 2019 guidelines produced by IWGDF.

The incidence of diabetes-related foot infections is expected to rise as the incidence of diabetes rises. In 2021, 537 million adults aged 20 to 79 years worldwide were living with diabetes.

Diabetes-related foot infections require frequent healthcare provider visits, daily wound care, antimicrobial therapy and surgical procedures, and are accompanied by high healthcare costs. They are the most frequent diabetes-related complications requiring hospitalization and the most common precipitating events leading to lower extremity amputation. 

Managing diabetes-related foot infections requires several steps: properly diagnosing the condition; obtaining appropriate specimens for culture; careful selection of antimicrobial therapy; quick determination of when surgical interventions are required; and provision of any needed additional wound care and overall patient care. 

The guidelines stress that management must focus on more than just treatment of the infection. It must include optimal local wound care (e.g., cleansing and debridement), pressure off-loading, peripheral vascular assessment (with revascularization if needed), and metabolic (particularly glycemic) control. If these aspects are not adequately addressed, the chance of treatment failure is greatly increased.

Key treatment-related recommendations in the guidelines:

• Do not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy when the goal is to reduce the risk of new infection or to promote ulcer healing. (Best Practice Statement). [Cultures of open wounds will usually reveal microorganisms, including some that are commonly considered pathogens, but this does not mean the wound is infected.]
• Use any of the systemic antibiotic regimens that have been shown to be effective in published randomized controlled trials at standard (usual) dosing to treat a person with diabetes and a soft tissue infection of the foot. (Strong; High). [The guidelines include a table summarizing proposed empiric antibiotic therapy according to clinical presentation and microbiological data.]
• Administer antibiotic therapy to a patient with a skin or soft tissue diabetic foot infection for a duration of one to two weeks. (Strong; High).
• Consider continuing treatment for up to three to four weeks if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease. (Conditional, Low).
• If evidence of infection has not resolved after four weeks of apparently appropriate therapy, re-evaluate the patient, and reconsider the need for further diagnostic studies or alternate treatments. (Strong; Low).
• Select an antibiotic agent based on the likely or proven causative pathogen(s) and their antibiotic susceptibilities; clinical severity of the infection; published evidence of efficacy of the agent for diabetes-related foot infections; risk of adverse events including collateral damage to the commensal flora; likelihood of drug interactions; agent availability and cost. (Best Practice Statement).
• Target aerobic gram-positive pathogens only (beta-hemolytic streptococci and Staphylococcus aureus,including methicillin-resistant strains if indicated) for people with a mild diabetes-related foot infection, who have not recently received antibiotic therapy. (Best Practice Statement).
• Consider a duration of up to three weeks of antibiotic therapy after minor amputation for diabetes-related osteomyelitis of the foot and positive bone margin culture; consider six weeks for diabetes-related foot osteomyelitis without bone resection or amputation. (Conditional; Low).
• To diagnose remission of diabetes-related osteomyelitis of the foot, use the outcome at a minimum follow-up duration of six months after the end of antibiotic therapy. (Best Practice Statement).
• Urgent surgical consultation should be obtained in situations of severe infection or moderate diabetes-related foot infections complicated by extensive gangrene, necrotizing infection, signs suggesting deep (below the fascia) abscess, compartment syndrome, or severe lower limb ischemia. (Best Practice Recommendation).
• Consider performing early (within 24–48 h) surgery combined with antibiotics for moderate and severe diabetes-related foot infections to remove the infected and necrotic tissue. (Conditional; Low).
• In people with diabetes, peripheral arterial disease and a foot ulcer or gangrene with infection involving any portion of the foot, obtain an urgent consultation by a surgical specialist as well as a vascular specialist in order to determine the indications and timings of a drainage and/or revascularization procedure. (Best Practice Statement).
• Consider performing surgical resection of infected bone combined with systemic antibiotics in a person with diabetes-related osteomyelitis of the foot. (Conditional; Low).
• Consider antibiotic treatment without surgery in case of forefoot osteomyelitis without an immediate need for incision and drainage to control infection, without peripheral arterial disease and without exposed bone. (Conditional; Low).
• The following treatments should not be used to address diabetes-related foot infections: adjunctive granulocyte colony-stimulating factor (G-CSF) treatment, topical antiseptics, silver preparations, honey, bacteriophage therapy, or negative-pressure wound therapy (with or without instillation). (Conditional; Low).
• Topical (sponge, cream, cement) antibiotics in combination with systemic antibiotics should not be used for treating either soft-tissue infections or osteomyelitis of the foot in patients with diabetes. (Conditional; Low).
• Available data did not allow making a recommendation on the use of rifampin for the treatment of diabetes-related osteomyelitis of the foot.

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The guidelines include a discussion of the rationale for each of the preceding (and other) recommendations. They also offer an algorithm that provides an overview of the diagnosis and management of patients with diabetes-related foot infections.

The guideline developers conclude with a series of questions regarding controversial topics or issues that require further investigation, such as how and when to determine whether an infection (including soft-tissue and osteomyelitis) has resolved; whether the currently recommended durations of antibiotic therapy can be reduced for soft-tissue infections and osteomyelitis; the place of various new antibiotics in the management of diabetes-related foot infections; and whether topical administration of antimicrobials can potentially limit the use of systemic antibiotics in diabetes-related foot infections.

Reference

1. Senneville E, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Clin Infect Dis 2023; online  October 2, 2023. https://www.idsociety.org/practice-guideline/diabetic-foot-infections/ (accessed October 10, 2023).

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