Table 3 Summary of the original IWGDF recommendation compared with the new Australian guideline recommendations for diabetes-related foot infections

1a

Diagnose a soft tissue diabetic foot infection clinically, based on the presence of local or systemic signs and symptoms of inflammation. (Strong; low)

Adopted

Diagnose a soft tissue diabetes-related foot infection clinically, based on the presence of local or systemic signs and symptoms of inflammation. (Strong; low)

1b

Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme. (Strong; moderate)

Adopted

Assess the severity of any diabetes-related foot infection using the International Working Group on the Diabetic Foot / Infectious Diseases Society of America classification scheme. (Strong; moderate)

2

Consider hospitalising all persons with diabetes and a severe (grade 4) foot infection and those with a moderate (grade 3) infection that is complex or associated with key relevant morbidities. (Strong; low)

Adopted

As stated in original IWGDF Recommendation

3

In a person with diabetes and a possible foot infection for whom the clinical examination is equivocal or uninterpretable, consider ordering an inflammatory serum biomarker, such as C-reactive protein, erythrocyte sedimentation rate, and perhaps procalcitonin, as an adjunctive measure for establishing the diagnosis. (Weak; low)

Adopted

As stated in original IWGDF Recommendation

4

As neither electronically measuring foot temperature nor using quantitative microbial analysis has been demonstrated to be useful as a method for diagnosing diabetic foot infection, we suggest not using them. (Weak; low)

Adopted

As neither electronically measuring foot temperature nor using quantitative microbial analysis has been demonstrated to be useful as a method for diagnosing diabetes-related foot infection, we suggest not using them. (Weak; low)

5

In a person with diabetes and suspected osteomyelitis of the foot, we recommend using a combination of the probe-to-bone test, the erythrocyte sedimentation rate (or C-reactive protein and/or procalcitonin), and plain X-rays as the initial studies to diagnose osteomyelitis. (Strong; moderate)

Adopted

As stated in original IWGDF Recommendation

6a

In a person with diabetes and suspected osteomyelitis of the foot, if a plain X-ray and clinical and laboratory findings are most compatible with osteomyelitis, we recommend no further imaging of the foot to establish the diagnosis. (Strong; low)

Adopted

As stated in original IWGDF Recommendation

6b

If the diagnosis of osteomyelitis remains in doubt, consider ordering an advanced imaging study, such as magnetic resonance imaging scan, 18F-FDG-positron emission tomography/computed tomography (CT) or leukocyte scintigraphy (with or without CT). (Strong; moderate)

Adopted

If the diagnosis of osteomyelitis remains in doubt, consider ordering an advanced imaging study, such as magnetic resonance imaging scan, 18F-FDG-positron emission tomography (PET)/computed tomography (CT) or leukocyte scintigraphy (with or without CT). (Strong; moderate)

7

In a person with diabetes and suspected osteomyelitis of the foot, in whom making a definitive diagnosis or determining the causative pathogen is necessary for selecting treatment, collect a sample of bone (percutaneously or surgically) to culture clinically relevant bone microorganisms and for histopathology (if possible). (Strong; low)

Adopted

As stated in original IWGDF Recommendation

8a

Collect an appropriate specimen for culture for almost all clinically infected wounds to determine the causative pathogens. (Strong; low)

Adopted

As stated in original IWGDF Recommendation

8b

For a soft tissue diabetic foot infection, obtain a sample for culture by aseptically collecting a tissue specimen (by curettage or biopsy) from the ulcer. (Strong; moderate)

Adopted

For a soft tissue diabetes-related foot infection, obtain a sample for culture by aseptically collecting a tissue specimen (by curettage or biopsy) from the ulcer. (Strong; moderate)

9

Do not use molecular microbiology techniques (instead of conventional culture) for the first-line identification of pathogens from samples in a patient with a diabetic foot infection. (Strong; low)

Adopted

Do not use molecular microbiology techniques (instead of conventional culture) for the first-line identification of pathogens from samples in a patient with a diabetes-related foot infection. (Strong; low)

10

Treat a person with a diabetic foot infection with an antibiotic agent that has been shown to be effective in a published randomized controlled trial and is appropriate for the individual patient. Some agents to consider include penicillins, cephalosporins, carbapenems, metronidazole (in combination with other antibiotic [s]), clindamycin, linezolid, daptomycin, fluoroquinolones, or vancomycin, but not tigecycline. (Strong; high)

Adopted

Treat a person with a diabetes-related foot infection with an antibiotic agent that has been shown to be effective in a published randomised controlled trial and is appropriate for the individual patient. Some agents to consider include penicillins, cephalosporins, carbapenems, metronidazole (in combination with other antibiotic [s]), clindamycin, linezolid, daptomycin, fluoroquinolones, or vancomycin, but not tigecycline. (Strong; high)

11

Select an antibiotic agent for treating a diabetic foot infection based on: the likely or proven causative pathogen(s) and their antibiotic susceptibilities; the clinical severity of the infection; published evidence of efficacy of the agent for diabetic foot infections; risk of adverse events, including collateral damage to the commensal flora; likelihood of drug interactions; agent availability; and, financial costs. (Strong; moderate)

Adopted

Select an antibiotic agent for treating a diabetes-related foot infection based on: the likely or proven causative pathogen(s) and their antibiotic susceptibilities; the 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, financial costs. (Strong; moderate)

12

Administer antibiotic therapy initially by the parenteral route to any patient with a severe (grade 4) diabetic foot infection. Switch to oral therapy if the patient is clinically improving and has no contraindications to oral therapy and if there is an appropriate oral agent available. (Strong; low)

Adapted

Administer antibiotic therapy initially by the parenteral route to any patient with a severe (grade 4) skin and soft tissue diabetes-related foot infection. Switch to oral therapy if the patient is clinically improving and has no contraindications to oral therapy and if there is an appropriate oral agent available. (Strong; very low)

13

Treat patients with a mild (grade 2) diabetic foot infection, and most with a moderate (grade 3) diabetic foot infection, with oral antibiotic therapy, either at presentation or when clearly improving with initial intravenous therapy. (Weak; low)

Adopted

Treat patients with a mild (grade 2) diabetes-related foot infection, and most with a moderate (grade 3) diabetes-related foot infection, with oral antibiotic therapy, either at presentation or when clearly improving with initial intravenous therapy. (Weak; low)

14

We suggest not using any currently available topical antimicrobial agent for treating a mild (grade 2) diabetic foot infection. (Weak; moderate)

Adopted

We suggest not using any currently available topical antimicrobial agent for treating a mild (grade 2) diabetes-related foot infection. (Weak; moderate)

15a

Administer antibiotic therapy to a patient with a skin or soft tissue diabetic foot infection for a duration of 1 to 2 weeks. (Strong; high)

Adopted

Administer antibiotic therapy to a patient with a skin or soft tissue diabetes-related foot infection for a duration of 1 to 2 weeks. (Strong; high)

15b

Consider continuing treatment, perhaps for up to 3 to 4 weeks, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease. (Weak; low)

Adopted

As stated in original IWGDF Recommendation

15c

If evidence of infection has not resolved after 4 weeks of apparently appropriate therapy, re-evaluate the patient, and reconsider the need for further diagnostic studies or alternative treatments. (Strong; low)

Adopted

As stated in original IWGDF Recommendation

16

For patients who have not recently received antibiotic therapy and who reside in a temperate climate area, target empiric antibiotic therapy at just aerobic gram-positive pathogens (beta-haemolytic streptococci and S. aureus) in cases of a mild (grade 2) diabetic foot infection. (Strong; low)

Adapted

For patients who have not recently received antibiotic therapy and have an acute infection, consider targeting empiric antibiotic therapy at just aerobic Gram positive pathogens (beta-haemolytic streptococci and Staphylococcus aureus) in cases of a mild (grade 2) diabetes-related foot infection. (Weak; low)

17

For patients residing in a tropical/subtropical climate, or who have been treated with antibiotic therapy within a few weeks, have a severely ischemic affected limb, or a moderate (grade 3) or severe (grade 4) infection, we suggest selecting an empiric antibiotic regimen that covers gram positive pathogens, commonly isolated gram-negative pathogens, and possibly obligate anaerobes in cases of moderate (grade 3) to severe (grade 4) diabetic foot infections. Then, reconsider the antibiotic regimen based on both the clinical response and culture and sensitivity results. (Weak; low)

Adapted

For patients who have been treated with antibiotic therapy within a few weeks, have a chronic infection, have a severely ischaemic affected limb, or a moderate (grade 3) or severe (grade 4) infection, we suggest selecting an empiric antibiotic regimen that covers Gram positive pathogens, commonly isolated Gram negative pathogens, and possibly obligate anaerobes in cases of moderate (grade 3) to severe (grade 4) diabetes-related foot infections. Then, reconsider the antibiotic regimen based on both the clinical response and culture and sensitivity results. (Weak; low)

18

Empiric treatment aimed at Pseudomonas aeruginosa is not usually necessary in temperate climates, but consider it if P. aeruginosa has been isolated from cultures of the affected site within the previous few weeks, or in tropical/subtropical climates (at least for moderate (grade 3) or severe (grade 4) infection). (Weak; low)

Adapted

Empiric treatment aimed at Pseudomonas aeruginosa is not usually necessary but consider it if P. aeruginosa has been isolated from cultures of the affected site within the previous few weeks, or in tropical/subtropical climates (at least for moderate [grade 3] or severe [grade 4] infection). (Weak; low)

19

Do not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy with the goal of reducing the risk of infection or promoting ulcer healing. (Strong; low)

Adopted

As stated in original IWGDF Recommendation

20

Nonsurgeons should urgently consult with a surgical specialist in cases of severe (grade 4) infection or of moderate (grade 3) infection complicated by extensive gangrene, necrotizing infection, signs suggesting deep (below the fascia) abscess or compartment syndrome, or severe lower limb ischemia. (Strong; low)

Adopted

Nonsurgeons should urgently consult with a surgical specialist in cases of severe (grade 4) infection or of moderate (grade 3) infection complicated by extensive gangrene, necrotising infection, signs suggesting deep (below the fascia) abscess or compartment syndrome, or severe lower limb ischaemia. (Strong; low)

21a

In a patient with diabetes and uncomplicated forefoot osteomyelitis, for whom there is no other indication for surgical treatment, consider treating with antibiotic therapy without surgical resection of bone. (Strong; moderate)

Adopted

As stated in original IWGDF Recommendation

21b

In a patient with probable diabetic foot osteomyelitis with concomitant soft tissue infection, urgently evaluate for the need for surgery as well as intensive post-operative medical and surgical follow-up. (Strong; moderate)

Adopted

In a patient with probable diabetes-related foot osteomyelitis with concomitant soft tissue infection, urgently evaluate the need for surgery as well as intensive post-operative medical and surgical follow-up. (Strong; moderate)

22

Select antibiotic agents for treating diabetic foot osteomyelitis from among those that have demonstrated efficacy for osteomyelitis in clinical studies. (Strong; low)

Adopted

Select antibiotic agents for treating diabetes-related foot osteomyelitis from among those that have demonstrated efficacy for osteomyelitis in clinical studies. (Strong; low)

23a

Treat diabetic foot osteomyelitis with antibiotic therapy for no longer than 6 weeks. If the infection does not clinically improve within the first 2 to 4 weeks, reconsider the need for collecting a bone specimen for culture, undertaking surgical resection, or selecting an alternative antibiotic regimen. (Strong; moderate)

Excluded

23b

Treat diabetic foot osteomyelitis with antibiotic therapy for just a few days if there is no soft tissue infection and all the infected bone has been surgically removed. (Weak; low)

Adopted

Treat diabetes-related foot osteomyelitis with antibiotic therapy for just a few days if there is no soft tissue infection and all the infected bone has been surgically removed. (Weak; low)

24

For diabetic foot osteomyelitis cases that initially require parenteral therapy, consider switching to an oral antibiotic regimen that has high bioavailability after perhaps 5 to 7 days, if the likely or proven pathogens are susceptible to an available oral agent and the patient has no clinical condition precluding oral therapy. (Weak; moderate)

Adopted

For people with diabetes-related foot osteomyelitis that initially require parenteral therapy, consider switching to an oral antibiotic regimen that has high bioavailability after perhaps 5 to 7 days, if the likely or proven pathogens are susceptible to an available oral agent and the patient has no clinical condition precluding oral therapy. (Weak; moderate)

25a

During surgery to resect bone for diabetic foot osteomyelitis, consider obtaining a specimen of bone for culture (and, if possible, histopathology) at the stump of the resected bone to identify if there is residual bone infection. (Weak; moderate)

Adopted

During surgery to resect bone for diabetes-related foot osteomyelitis, consider obtaining a specimen of bone for culture (and, if possible, histopathology) at the stump of the resected bone to identify if there is residual bone infection. (Weak; moderate)

25b

If an aseptically collected culture specimen obtained during the surgery grows pathogen(s), or if the histology demonstrates osteomyelitis, administer appropriate antibiotic therapy for up to 6 weeks. (Strong; moderate)

Adopted

As stated in original IWGDF Recommendation

26

For a diabetic foot infection, do not use hyperbaric oxygen therapy or topical oxygen therapy as an adjunctive treatment if the only indication is specifically for treating the infection. (Weak; low)

Adopted

For a diabetes-related foot infection, do not use hyperbaric oxygen therapy or topical oxygen therapy as an adjunctive treatment if the only indication is specifically for treating the infection. (Weak; low)

27a

To specifically address infection in a diabetic foot ulcer do not use adjunctive granulocyte colony stimulating factor treatment (Weak; moderate)

Adopted

As stated in original IWGDF Recommendation

27b

To specifically address infection in a diabetic foot ulcer do not routinely use topical antiseptics, silver preparations, honey, bacteriophage therapy, or negative pressure wound therapy (with or without instillation). (Weak; low)

Adopted

To specifically address infection in a diabetes-related foot ulcer do not routinely use topical antiseptics, silver preparations, honey, bacteriophage therapy, or negative pressure wound therapy (with or without instillation). (Weak; low)