This means using narrow-spectrum antibiotics first where possible, and using microbiological results, when available, to guide treatment. The committee discussed options for providing education and support outside of foot assessments (for example, remote appointments). However, it was not clear how feasible it would be to run these extra appointments in practice.
Assessing the risk of developing a diabetic foot problem
The committee agreed that a shorter course was generally as effective as a longer course for adults with a mild diabetic foot infection, and a 7‑day course was sufficient for most people. However, it agreed that a longer course (up to a further 7 days) may be needed for some people based on a clinical assessment of their symptoms and history. They discussed the limited evidence on antibiotic course length, which compared 6 weeks with 12 weeks in adults with diabetic foot osteomyelitis.
Rationale and impact
The committee also discussed factors that would indicate that a person with a diabetic foot infection would need to be reassessed. These included if an infection was rapidly or significantly worsening or not improving, if other diagnoses were possible, or symptoms suggested a more serious illness or condition. The committee based the recommendation on their experience and safety netting advice from the NICE guideline on antimicrobial stewardship. They agreed that if symptoms worsened rapidly or significantly at any time, or did not improve within 1 to 2 days, people with a diabetic foot infection should be advised to seek medical help.
Given this evidence, the committee discussed reducing the frequency of foot risk assessments to once every 2 years. For a short explanation of why the committee did not change the recommendations that were reviewed in 2023, and how this might affect practice, see the rationale and impact section on assessing the risk of developing a diabetic foot problem. The committee agreed to retain the 2015 recommendation that antibiotics should not be given to prevent diabetic foot infections. No evidence was identified for antibiotic prophylaxis and the committee agreed that antibiotic prophylaxis is not appropriate because of concerns about antimicrobial resistance. People should be advised to seek medical help if symptoms of a diabetic foot infection develop.
Medical technologies guidance (
- The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition.
- They recommended that if a diabetic foot infection is suspected or confirmed in children or young people, specialist advice should be sought regarding antibiotic choice and regimen.
- We use the best available evidence to develop recommendations that guide decisions in health, public health and social care.
- These antibiotics may also be appropriate in other situations based on microbiological results and specialist advice.
- The committee based the recommendation on their experience and safety netting advice from the NICE guideline on antimicrobial stewardship.
- ‘Diabetic foot problem’ refers to any problem affecting the feet in people with diabetes that is caused by loss of sensation (peripheral sensory neuropathy) and/or circulation problems (peripheral arterial disease).
These recommendations should ensure that appropriate reassessment is in place. But the antibiotics used in the studies were not wholly representative of UK practice, with some not being available in the UK and others not widely used. However, there were differences between some antibiotic classes, with lower rates of adverse effects generally for beta-lactam antibiotics. Local infection with erythema more than 2 cm around the ulcer or involving structures deeper than skin and subcutaneous tissues (such as abscess, osteomyelitis, septic arthritis or fasciitis), and no systemic inflammatory response signs.
2 Care across all settings
Diabetes is a chronic condition and people may have had previous foot infections, with previous courses of antibiotics, that will influence their preferences. The committee retained the 2015 recommendation that samples should be taken for microbiological testing before, or as close as possible to, the start gen z alphabet of antibiotic treatment. This would allow empirical antibiotic treatment to be changed if needed when results are available. All the risk assessment tools reviewed by the committee were able to predict ulcer occurrence with acceptable accuracy.
Patient information about diabetic foot problems
- The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available.
- The committee agreed that in people with diabetes, all foot wounds are likely to be colonised with bacteria.
- They agreed that if symptoms worsened rapidly or significantly at any time, or did not improve within 1 to 2 days, people with a diabetic foot infection should be advised to seek medical help.
- This would allow empirical antibiotic treatment to be changed if needed when results are available.
- We do not mean to imply that people with diabetes should be blamed for their foot problems, and they should still be treated as individuals with their own needs, preferences and values.
In line with the NICE guideline on antimicrobial stewardship and Public Health England’s Start smart – then focus, the committee agreed that oral antibiotics should be used in preference to intravenous antibiotics where possible. Intravenous antibiotics should only be used for people who are severely ill, unable to tolerate oral treatment, or where oral treatment would not provide adequate coverage or tissue penetration. The use of intravenous antibiotics should be reviewed by 48 hours (taking into account the person’s response to treatment and any microbiological results) and switched to oral treatment where possible. The annual foot assessment is not just a foot examination and risk assessment.
For a short explanation of why the committee did not change the recommendations that were reviewed in 2023, and how this might affect practice, see the rationale and impact section on managing the risk of developing a diabetic foot problem. No evidence was identified comparing antibiotic dose, frequency or route of administration. This guideline uses ‘diabetic foot problem’ throughout, because this is the term healthcare professionals will most commonly recognise for foot problems in people with diabetes. We do not mean to imply that people with diabetes should be blamed for their foot problems, and they should still be treated as individuals with their own needs, preferences and values. For a short explanation of why the committee made these 2019 recommendations and how they might affect practice, see the rationale and impact section on choice of antibiotic, dose frequency, route of administration and course length. The committee agreed that the choice of antibiotic in adults should be based on severity of infection (mild, moderate or severe) and the risk of complications, while minimising adverse effects and antibiotic resistance.
Foot assessments are currently part of the annual diabetes review, so it makes sense to continue to include the foot check and risk assessment in that appointment. There are also Quality and Outcomes Framework (QOF) indicators for annual foot examination and risk classification, which further justify retaining the current system. Base antibiotic course length on the severity of the infection and a clinical assessment of response to treatment. Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics. We reviewed this guideline and will update the recommendations on treatment for diabetic foot ulcer in specific relation to considering topical oxygen therapy.
For information about individual topics, including any decisions affecting this guideline, see the summary table of prioritisation board decisions. Start by checking that Apple Music is installed on your smartphone or iPad and that you have an active Apple Music subscription. Then simply download and install the Apple Music Classical app on the same device and you’re all set. The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions. The recommendations aim to optimise antibiotic use and reduce antibiotic resistance.
Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. We use the best available evidence to develop recommendations that guide decisions in health, public health and social care. Patient preference is also important, particularly for treatment that will involve a hospital stay or be prolonged.
These sections briefly explain why the committee made the recommendations and how they might affect practice. Local infection with signs of systemic inflammatory response (such as temperature of more than 38°C or less than 36°C, increased heart rate or increased respiratory rate). Skin takes some time to return to normal, and full resolution of symptoms after a course of antibiotics is not expected. The treatment will depend on how severe the ulcer is, where it is, and what you would prefer.
For a short explanation of why the committee made this 2019 recommendation and how it might affect practice, see the rationale and impact section on prevention. You’ll need to have regular appointments as part of your treatment plan – how often will depend on your overall health, how well the ulcer heals, and whether any other problems develop. All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.