This is the current release of the guideline.

Definitions for the quality of the evidence (I-III) and strength of recommendation (A-E) are given at the end of the "Major Recommendations" field.

1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity.
2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II). The team managing these infections should include, or have ready access to, an infectious disease specialist or a medical microbiologist (B-II).
3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role.
4. Aerobic gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens.
5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II).
6. Send appropriately obtained specimens for culture prior to starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I).
7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but magnetic resonance imaging (MRI) (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I).
8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management.
9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care.
10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III).
11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I).
12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 1-2 weeks usually suffices, but some require an additional 1-2 weeks; for moderate and severe infections, usually 2-4 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 4-6 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II).
13. If an infection in a clinically stable patient fails to respond to >1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III).
14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible.
15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds.
16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III).
17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors.
18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from noninfectious osteoarthropathy. Clinical examination and imaging tests may suffice, but bone biopsy is valuable for establishing the diagnosis of osteomyelitis, for defining the pathogenic organism(s), and for determining the antibiotic susceptibilities of such organisms (B-II).
19. Although this field has matured, further research is much needed. The committee especially recommends that adequately powered prospective studies be undertaken to elucidate and validate systems for classifying infection, diagnosing osteomyelitis, defining optimal antibiotic regimens in various situations, and clarifying the role of surgery in treating osteomyelitis (A-III).

Definitions

Quality of Evidence

1. Evidence from >1 properly randomized, controlled trial
2. Evidence from >1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies (preferably from >1 center); from multiple time-series; or from dramatic results from uncontrolled experiments
3. Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Strength of Recommendation

1. Good evidence to support a recommendation for use; should always be offered
2. Moderate evidence to support a recommendation for use; should generally be offered
3. Poor evidence to support a recommendation; optional
4. Moderate evidence to support a recommendation against use; should generally not be offered
5. Good evidence to support a recommendation against use; should never be offered

The original guideline provides the following algorithms:

• Algorithm 1, part 1: Approach to treating a diabetic patient with a foot wound
• Algorithm 1, part 2: Approach to treating a diabetic with a foot infection
• Algorithm 1, part 3: Approach to assessing a diabetic patient with a foot infection who is not responding well to treatment
• Algorithm 2: Approach to selecting antibiotic therapy for a diabetic with a foot infection
• Algorithm 3: Evaluating a diabetic patient who has suspected osteomyelitis of the foot

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2004 Oct 1

Infectious Diseases Society of America - Medical Specialty Society

Infectious Diseases Society of America (IDSA)

Infectious Diseases Society of America (IDSA) Practice Guidelines Committee

Authors: Benjamin A. Lipsky, Medical Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Anthony R. Berendt, Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, United Kingdom; H. Gunner Deery, Northern Michigan Infectious Diseases, Petoskey, Michigan; John M. Embil, Section of Infectious Diseases, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; Warren S. Joseph, Section of Podiatry, Department of Primary Care, Veterans Affairs Medical Center, Coatesville, Pennsylvania; Adolf W. Karchmer, Division of Infectious Diseases, Department of Medicine, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, Massachusetts; Jack L. LeFrock, Dimensional Dosing Systems, Sarasota, Florida; Daniel P. Lew, Department of Medicine, Service of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; Jon T. Mader, Department of Internal Medicine, The Marine Biomedical Institute, and Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, Galveston, Texas; Carl Norden, Department of Medicine, New Jersey School of Medicine and Dentistry, and Cooper Hospital, Camden, New Jersey; James S. Tan, Department of Internal Medicine, Summa Health System, and Northeastern Ohio Universities College of Medicine, Akron, Ohio

Benjamin A. Lipsky: Advisory board membership, research support from, or speaker's bureau for Pfizer, Merck, Wyeth-Ayerst, Cubist, Vicuron, and Ortho-McNeil.

Anthony R. Berendt: Speaker's bureau for Pfizer.

H. Gunner Deery: Speaker's bureau for GlaxoSmithKline and Pfizer, and research support from Theravance.

John M. Embil: Advisory board membership, research support from, or speaker's bureau for AstraZeneca, Bayer, Bristol-Myers Squibb, Eli Lilly, Fujisawa, Janssen Ortho, and Pfizer.

Warren S. Joseph: Consultant and speaker's bureau for Pfizer and Merck.

Adolf W. Karchmer: Research support from Bayer, Pfizer, Merck, Ortho-McNeil, Cubist, Pharmacia, Vicuron, and Fujisawa and advisory board for Aventis, Pfizer, King Pharmaceuticals, Chiron, Vicuron, Cubist, and Bayer.

Carl Norden: Former employee of Pfizer.

James S. Tan: Research support from and speaker's bureau for Wyeth, Merck, Pfizer, Ortho-McNeil, Bayer, and Glaxo-SmithKline.

Jack L. LeFrock and Daniel P. Lew: No conflict.

This is the current release of the guideline.

None available

This summary was completed by ECRI on November 5, 2004.

This NGC summary is based on the original guideline, which may be subject to the guideline developer's copyright restrictions.