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  • The Review Course in Family Medicine

Guideline Alert - Diagnosis and Treatment of Diabetic Foot Infections

Managing Diabetic Foot Infections (DFI) is critical, and the IWGDF-IDSA classification provides a roadmap for effective care.

1. Classify diabetic foot infections (DFI) with the IWGDF-IDSA classification (See table below). 2. Consider hospitalization for moderate to severe infections.

3. While DFI are polymicrobial, wound cultures can help guide treatment. Empiric coverage for methicillin-resistant Staphylococcus aureus (MRSA)/pseudomonas is not recommended unless isolated or in high-risk individuals.

4. Assess for osteomyelitis with probe-to-bone test and plain X-rays. If there is uncertainty, consider further imagine (follow local practice patterns, CT Foot, for e.g. Remember to specifically state the body part you are imaging).

5. Send bone samples along with tissue samples if there is concern for osteomyelitis.

6. Only treat foot ulcers if there are clinical signs of infection.

7. Treat DFI with systemic antibiotics for 1-2 weeks, extend to 3 weeks in patients with peripheral arterial disease (PAD) or if progress is slow, and extend to 6 weeks if signs of osteomyelitis.

8. Get an urgent surgical consult for signs of gangrene, deep infections or severe ischemia.

9. The use of hyperbaric oxygen, concurrent topical antibiotics or negative pressure wound therapy is not recommended.

With this guidance, we optimize DFI management, ensuring tailored care and better patient outcomes.




​No clinical signs or symptoms of infection.

Mild Infection (Superficial)

Infection involving only the skin and subcutaneous tissue. No systemic signs of infection.

​Moderate Infection (Soft Tissue)

Deeper infection involving structures beyond skin and subcutaneous tissue. May exhibit systemic signs of infection, but the patient is not severely ill.

Severe Infection

Deep and extensive infection, often involving muscle, bone, or joint. Systemic signs of severe illness are present (e.g., fever, tachycardia, hypotension).

Extensive Limb-Threatening Infection

Infection that poses a threat to the limb's viability. Often includes severe infection with evidence of tissue necrosis or gangrene.

​Necrotizing Infection

Critical infection characterized by extensive tissue death and systemic toxicity. Immediate surgical intervention is often required to save the limb or the patient's life.


Éric Senneville, Zaina Albalawi, Suzanne A van Asten, Zulfiqarali G Abbas, Geneve Allison, Javier Aragón-Sánchez, John M Embil, Lawrence A Lavery, Majdi Alhasan, Orhan Oz, Ilker Uçkay, Vilma Urbančič-Rovan, Zhang-Rong Xu, Edgar J G Peters, IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023), Clinical Infectious Diseases, 2023;, ciad527,



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