Diabetic Foot Infection Prevention and Management

Risk Assessment and Screening

The International Working Group on the Diabetic Foot (IWGDF) recommends screening all people with diabetes annually for signs of peripheral neuropathy and peripheral arterial disease (PAD) to determine risk of foot ulceration using the IWGDF risk stratification system 1, 2
For patients with loss of protective sensation or PAD, screening should assess for limited joint mobility 1, foot deformity 3, and pre-ulcerative lesions 1, 2
Screening frequency should be adjusted based on risk level, with IWGDF risk 1 screened every 6-12 months 1, IWGDF risk 2 screened every 3-6 months 1, and IWGDF risk 3 screened every 1-3 months 1, 2

Patients at risk of foot ulceration (IWGDF risk 1-3) should be educated to never walk barefoot, in socks without shoes, or in thin-soled slippers 1, 3
Patients should be instructed to wash feet daily with careful drying, particularly between toes 1, 3, use emollients to moisturize dry skin 1, 3, cut toenails straight across 1, 3, and examine feet daily for any changes or lesions 1, 3
Patients should contact healthcare professionals immediately if pre-ulcerative lesions are detected 1, 3

Patients with no/limited foot deformity (IWGDF risk 1-3) should be educated on wearing properly fitting footwear that accommodates foot shape 1, 3
Patients with foot deformity or pre-ulcerative lesions (IWGDF risk 2-3) should be considered for extra-depth shoes, custom-made footwear, insoles, or toe orthoses 1, 3
Patients with healed plantar foot ulcers (IWGDF risk 3) should be prescribed therapeutic footwear with demonstrated plantar pressure-relieving effect during walking 1, 3

Low-to-moderate risk patients should be considered for a supervised foot-ankle exercise program to reduce ulcer risk factors 2, 3
An increase in weight-bearing activity of 1000 steps/day is likely safe regarding ulceration risk 2, 3
Patients with active lesions should limit standing and walking, using mobility aids if necessary 6, 7

A multidisciplinary foot care team approach should be implemented to reduce diabetes-related lower extremity amputations 4, 6, 7
Care should be organized at appropriate levels, including general practitioner, podiatrist, diabetic nurse 1, and specialized diabetic foot care center with multiple experts 4, 6

Foot ulcers should be determined to be infected before starting antibiotics 5
For mild infections, cleanse, debride necrotic tissue and callus, and start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 4, 6, 5
For moderate to severe infections, consider surgical intervention, assess for PAD, and initiate broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 4, 6, 5