#5 2019 updated IWGDF guidelines
Guidelines on the diagnosis and treatment of foot infection in
persons with diabetes (IWGDF 2019 update)
Diabetes Metab Res Rev. 2020;36(S1):e3280.
Benjamin A. Lipsky, Éric Senneville, Zulfiqarali G. Abbas, Javier Aragón-Sánchez, Mathew Diggle, John M. Embil, Shigeo Kono, Lawrence A. Lavery, Matthew Malone, Suzanne A. van Asten, Vilma Urbancic-Rovan, Edgar J.G. Peters on behalf of the International Working
Group on the Diabetic Foot (IWGDF)
Since this is a clinical practice guideline from an international body, this is the kind of article that anyone who takes care of patients with diabetic foot infection should read and know. I would recommend to anyone who is reading my blog posts that, at the very least, they obtain this article to read the summary list of recommendations, which number 27. In my practice, I do get referrals for patients who have been receiving treatment, sometimes for months, where opportunities for earlier evidence-based treatment were missed, and I will highlight a few of the recommendations that I think are particularly important.
Recommendation #2: Consider hospitalizing patients with severe foot infection and those with moderate infection that is complex or associated with key relevant modalities. The reason I highlight this recommendation is that I do see patients who have exposed bone with signs of inflammation and no vascular exam who are treated with oral antibiotics and lack of timely referral. Hospitalization in these kinds of patients will allow for more rapid assessment and treatment of comorbidities such as peripheral arterial disease and osteomyelitis.
Recommendation #20: Urgently consult with a surgical specialist in cases of severe infection or of moderate infection complicated by gangrene, necrosis, abscess, compartment syndrome, or severe lower limb ischemia. I think this should be obvious, but I have been surprised before when patients have visible gas on an x-ray yet did not have an emergent surgical consultation.
Recommendation #23: Treat osteomyelitis with antibiotic therapy for no longer than six weeks. If the infection does not clinically improve within the first 2 to 4 weeks, reconsider the need for bone culture, surgical resection, or alternative antibiotic regimen. I have highlighted this recommendation because of the need to re-evaluate the clinical situation if the patient does not improve as expected. Without this re-evaluation, you will miss the possible reason for the lack of improvement and the necessary treatment change to get back on track.
Lastly, I feel these recommendations are missing the importance of adequately assessing the arterial perfusion to these wounds. Yes, they do recommend urgent consultation in case of severe lower limb ischemia, but they should also be recommending vascular evaluation in cases where patients are not responding as expected. Please note that while an abnormal ankle-brachial index (ABI) indicates the likely presence of peripheral arterial disease in patients with diabetes mellitus, the false-negative rate is too high to rely upon that as an adequate screening tool. Therefore, if the goal is to rule out the presence of peripheral arterial disease as the cause of failure to improve in this patient population, other testing, such as toe pressure, pulse volume recording, skin perfusion pressure, transcutaneous oximetry, or arterial ultrasound should be considered. One note of caution concerning interpreting arterial ultrasound reports. I have had many referring colleagues believe an arterial ultrasound report was negative for peripheral arterial disease when the radiologist did not report on the presence of stenosis despite the transition from triphasic to monophasic waveform above the wound. When there is a change in the waveform, there should be suspicion for the presence of stenosis, and these patients require vascular referral. Many times, clinically significant stenosis is found on the subsequently performed angiogram.