Diabetes-related foot infections: An update on the latest guidelines

Foot infections are the most frequent complication related to diabetes that requires hospitalization and the most common precipitating event leading to lower extremity amputations. But timely diagnosis and treatment can prevent the worst effects of these infections. Éric Senneville, MD, PhD, a specialist in infectious diseases at France’s Gustave Dron Hospital — and the lead author of new guidelines on the topic from IDSA and the International Working Group on the Diabetic Foot — answered several questions from Science Speaks about the new guidelines, including the most notable updates and how the guideline supports antimicrobial stewardship.

Who are these new guidelines intended for? In what health care settings do you envision the guidelines having the most impact?

The 2023 guidelines are intended to provide the best evidence about the diagnosis and treatment of people with diabetes and diabetes-related foot infections. These guidelines aim to help physicians and other health care workers involved in the management of people with diabetes and foot problems, including general practitioners, nurses and medical specialists (internists, diabetologists, general orthopedic surgeons, radiologists, nuclear medicine, infectiologists, biologists, etc.). This broad panel reflects the multidisciplinary approach that should be used as much as feasible to improve the prognosis of these potentially catastrophic infections.          

What are the most notable updates or recommendation changes compared to the previously published guidelines on this topic?

The most notable updates we made compared to the 2019 IWGDF guidelines and the 2012 IDSA guidelines are:

• We propose reducing the duration of the antibiotic therapy to 10 days in patients with severe or moderate soft-tissue infections of the foot following surgical debridement.
• We now have data that support the safety of bedside percutaneous bone biopsy in persons with a suspicion of diabetes-related osteomyelitis of the foot, or DFO.
• We reduced the post-end of treatment follow-up necessary to define a remission of a DFO from 12 to 6 months.

Of note, this 2023 edition of the guidelines on infection is the first one ever that combines the IWGDF and IDSA guidelines in a collaborative document on diabetes-related foot infections.

How do you see these guidelines contributing to antimicrobial stewardship efforts?

We think that the IWGDF/IDSA guidelines contribute to antimicrobial stewardship efforts essentially by providing recommendations for (i) strict indications for sampling wounds, (ii) the best way to perform them to avoid the misuse of broad-spectrum antibiotic regimens and (iii) reducing the duration of the exposure of the patients to antibiotics.

How much has our knowledge about these infections changed since the guidelines were last updated? Have there been any major research advances in this area that are reflected in the guidelines?

The current IWGDF/IDSA guidelines globally confirm the recommendations we made in 2019 with an improved methodology. The improved methodology included applying Grading of Recommendations Assessment, Development and Evaluation principles. New evidence identified was evaluated on the basis of shared outcomes that had been revised to include direct and patient-centered outcomes. Certainty of evidence and Evidence to Decision frameworks were used as well from GRADE to ensure transparency, applicability and contextualization of the recommendations made.

What are some key questions still to be answered about these infections?

We still need well-designed studies to address the best way to classify DFIs according to the infection severity, the potential benefit of using molecular techniques (including metagenomic next-generation sequencing methods) and the place of positron emission tomography for the diagnosis of DFO as well as the impact of using routine bone biopsy and rifampicin use in patients with DFO.

Read the new guidelines, “IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections.”