2023 IWGDF/IDSA Guidelines for Treatment of Diabetes-Related Foot Infections

The International Working Group on the Diabetic Foot (IWGDF) and Infectious Diseases Society of America (IDSA) developed evidence-based guidelines for the diagnosis and therapeutic management of foot infections among patients with diabetes. The full guidelines were published simultaneously in Diabetes/Metabolism: Research & Reviews and Clinical Infectious Diseases. 

Using the Grading of Recommendations, Assessment, Development, and Evaluation framework, a multidisciplinary working group of experts from IWGDF and IDSA updated the 2019 guidelines to inform patient-centered, clinical care for diabetes-related foot infections (DFIs). 

Overview of Guidelines for the Diagnosis and Management of DFIs

Diagnosis of Infection and Hospitalization

1. The working group strongly recommended that soft-tissue DFI be diagnosed based on the presence of local or systemic inflammation. Clinicians should assess DFIs for the presence of an infection and rate its severity accordingly. 

2. In addition, clinicians must consider hospitalizing patients with diabetes with a moderate to severe foot infection due to an increased risk for poor outcomes, including amputation and death. The working group recommended hospital admission for patients requiring intravenous antibiotic therapy.

Collection of Samples

3. As a best practice, the working group suggested assessment of serum biomarkers, including C-reactive protein, erythrocyte sedimentation rate, and procalcitonin, among patients with diabetes and suspected infection of a foot ulcer.

4. Clinicians should aim to determine the causative microorganism by collecting tissue specimens from the wounds of patients with DFIs and possibly repeating cultures for those with an inadequate response to therapy. 

5. Among patients with suspected osteomyelitis of the foot, bone samples, compared with soft-tissue samples, may be more accurate indicators of the causative pathogen. Samples may be collected during surgery or through the skin.

Choosing the Appropriate Diagnostic Method

6. The working group conditionally recommended against the use of foot temperature and quantitative microbial analysis as DFI screening tests, as they may result in an over-diagnosis of infected foot ulcers among this patient population. 

7. The working group strongly recommended that clinicians use conventional vs molecular microbiology techniques to identify pathogens responsible for soft tissue and bone infections and their antibiotic sensitivities.

8. A combination of screening tests, including probe-to-bone, x-ray, erythrocyte sedimentation rate, C-reactive protein, and procalcitonin, may be preferable to determine the presence of osteomyelitis of the foot. The working group cautioned about (1) the importance of timely and accurate diagnosis of bone infection in the foot, (2) prolonged antibiotic treatment, and (3) the risk for amputations. 

9. The working group strongly recommended the use of magnetic resonance imaging (MRI) in the event that other diagnostic methods were inconclusive. 

10. The working group conditionally recommended the use of positron emission tomography, leucocyte scintigraphy, or single-photon emission computerized tomography as an alternative to MRI scanning.  

Treatment With Antibiotics

1. Choice of Antibiotics

11. As a best practice, the working group recommended against the treatment of uninfected foot ulcers with antibiotics, especially for prophylaxis or ulcer healing. 

12. The working group recommended antibiotic therapy selection based on the causative microorganism. They also noted the importance of considering other factors, such as antibiotic susceptibility, infection severity, risk for adverse events, and drug interactions.

13. As a best practice statement, the working group suggested targeting aerobic gram-negative bacteria among patients with DFI in the US and Europe without a recent history of antibiotic exposure. For Pseudomonas aeruginosa, the use of empirical antibiotic therapy was recommended if samples were recently isolated from patients with moderate to severe infection.

14. Due to conflicting results in the literature, the group recommended against a combination of topical and systemic antibiotics for soft-tissue and bone infections among patients with diabetes. 

2. Dosage & Timing of Antibiotics

15. If a DFI is confirmed, standard-dose systemic antibiotic therapy for a duration of 1 to 2 weeks should be prescribed. If infection is severe, healing is slower than expected, or patients have severe peripheral artery disease (PAD), clinicians may continue treatment for up to 4 weeks. If infection has not resolved after 4 weeks, the infection must be re-evaluated and alternative treatments must be considered. 

16. Among patients with diabetes-related foot osteomyelitis and positive bone margin culture who had an amputation, antibiotics may be administrated at the upper dosage range for up to 3 weeks after surgery. For those without bone resection or amputation, antibiotics may be administered for 6 weeks.

17. As a best practice, the working group indicated that clinicians should follow up with patients with diabetes-related osteomyelitis for at least 6 months after the completion of antibiotic therapy to call it a “remission.” Furthermore, clinicians should follow up with these patients on a regular basis due to the high risk for potential foot complications.

Surgical Treatment

18. Among patients with moderate to severe DFIs with complications, including gangrene, necrotizing infection, or lower limb ischemia, the working group suggested the consideration of urgent surgical consultation, especially for cases in which nonsurgical treatment may fail.

19. The working group conditionally recommended the performance of surgery within 48 hours to remove the infected tissue among patients with moderate to severe DFIs. Along with a surgical consult, clinicians must seek the guidance of a vascular specialist for patients with diabetes with PAD and foot ulcers or gangrene.

20. Clinicians may consider surgical resection of the infected bone, along with antibiotic therapy, among patients with diabetes and foot osteomyelitis. However, surgery may be avoided (only antibiotics) among patients with forefoot osteomyelitis, those without PAD, and those without exposed bone. 

Use of Adjunctive Therapies for DFIs

21. Due to lack of evidence on effectiveness for wound healing, the working group recommended against the use of adjunctive granulocyte colony‐stimulating factor and topical antiseptics, silver preparations, honey, bacteriophage therapy, or negative-pressure wound therapy. 

22. The working group also recommended against the use of hyperbaric oxygen therapy and topical oxygen therapy, as adjunctive therapy for the treatment of DFIs.

Guideline authors concluded that adherence to these guidelines “will help healthcare professionals provide care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes‐related foot disease.”