Diabetic foot problems: prevention and management

Frequency of assessments

• For children with diabetes who are under 12 years, give them, and their family members or carers (as appropriate), basic foot care advice
• For young people with diabetes who are 12–17 years, the paediatric care team or the transitional care team should assess the young person’s feet as part of their annual assessment, and provide information about foot care. If a diabetic foot problem is found or suspected, the paediatric care team or the transitional care team should refer the young person to an appropriate specialist
• For adults with diabetes, assess their risk of developing a diabetic foot problem at the following times:
  • When diabetes is diagnosed, and at least annually thereafter
  • If any foot problems arise

Assessing the risk of developing a diabetic foot problem

• When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings, and examine both feet for evidence of the following risk factors:
  • Neuropathy (use a 10 g monofilament as part of a foot sensory examination)
  • Limb ischaemia (see the NICE guideline on peripheral arterial disease)
  • Ulceration
  • Callus
  • Infection and/or inflammation
  • Deformity
  • Gangrene
  • Charcot arthropathy
• Use ankle brachial pressure index in line with the NICE guideline on peripheral arterial disease. Interpret results carefully in people with diabetes because calcified arteries may falsely elevate results
• Assess the person’s current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification:
  • Low risk:
    • no risk factors present except callus alone
  • Moderate risk:
    • deformity or
    • neuropathy or
    • non-critical limb ischaemia.
  • High risk:
    • previous ulceration or
    • previous amputation or
    • on renal replacement therapy or
    • neuropathy and non-critical limb ischaemia together or
    • neuropathy in combination with callus and/or deformity or
    • non-critical limb ischaemia in combination with callus and/or deformity
  • Active diabetic foot problem:
    • ulceration or
    • spreading infection or
    • critical limb ischaemia or
    • gangrene or
    • suspicion of an acute Charcot arthropathy, or an unexplained hot, red, swollen foot with or without pain

Managing the risk of developing a diabetic foot problem

• For people who are at low risk of developing a diabetic foot problem, continue to carry out annual foot assessments, emphasise the importance of foot care, and advise them that they could progress to moderate or high risk
• Refer people who are at moderate or high risk of developing a diabetic foot problem to the foot protection service
• The foot protection service should assess newly referred people as follows:
  • Within 2–4 weeks for people who are at high risk of developing a diabetic foot problem
  • Within 6–8 weeks for people who are at moderate risk of developing a diabetic foot problem
• For people at moderate or high risk of developing a diabetic foot problem, the foot protection service should:
  • Assess the feet
  • Give advice about, and provide, skin and nail care of the feet
  • Assess the biomechanical status of the feet, including the need to provide specialist footwear and orthoses
  • Assess the vascular status of the lower limbs
  • Liaise with other healthcare professionals, for example, the person’s GP, about the person’s diabetes management and risk of cardiovascular disease
• Depending on the person’s risk of developing a diabetic foot problem, carry out reassessments at the following intervals:
  • Annually for people who are at low risk
  • Frequently (for example, every 3–6 months) for people who are at moderate risk
  • More frequently (for example, every 1–2 months) for people who are at high risk, if there is no immediate concern
  • Very frequently (for example, every 1–2 weeks) for people who are at high risk, if there is immediate concern
• Consider more frequent reassessments for people who are at moderate or high risk, and for people who are unable to check their own feet

Patient information about the risk of developing a diabetic foot problem

• Provide information and clear explanations to people with diabetes and/or their family members or carers (as appropriate) when diabetes is diagnosed, during assessments, and if problems arise. Information should be oral and written, and include the following:
  • Basic foot care advice and the importance of foot care
  • Foot emergencies and who to contact
  • Footwear advice
  • The person’s current individual risk of developing a foot problem
  • Information about diabetes and the importance of blood glucose control.^[A]

Diabetic foot problems

Referral

• If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services and inform the multidisciplinary foot care service (according to local protocols and pathways), so they can be assessed and an individualised treatment plan put in place. Examples of limb-threatening and life-threatening diabetic foot problems include the following:
  • Ulceration with fever or any signs of sepsis
  • Ulceration with limb ischaemia (see the NICE guideline on peripheral arterial disease)
  • Clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration)
  • Gangrene (with or without ulceration)
• For all other active diabetic foot problems, refer the person within 1 working day to the multidisciplinary foot care service or foot protection service (according to local protocols and pathways) for triage within 1 further working day

Patient information about diabetic foot problems

• Provide information and clear explanations as part of the individualised treatment plan for people with a diabetic foot problem. Information should be oral and written, and include the following:
  • A clear explanation of the person’s foot problem
  • Pictures of diabetic foot problems
  • Care of the other foot and leg
  • Foot emergencies and who to contact
  • Footwear advice
  • Wound care
  • Information about diabetes and the importance of blood glucose control.^[A]
• If a person presents with a diabetic foot problem, take into account that they may have an undiagnosed, increased risk of cardiovascular disease that may need further investigation and treatment. For guidance on the primary prevention of cardiovascular disease, see the NICE guideline on cardiovascular disease: risk assessment and reduction, including lipid modification.

Diabetic foot ulcer

Investigation

• If a person has a diabetic foot ulcer, assess and document the size, depth and position of the ulcer
• Use a standardised system to document the severity of the foot ulcer, such as the SINBAD (Site, Ischaemia, Neuropathy, Bacterial Infection, Area and Depth) or the University of Texas classification system
• Do not use the Wagner classification system to assess the severity of a diabetic foot ulcer

Treatment

• Offer one or more of the following as standard care for treating diabetic foot ulcers:
  • Offloading
  • Control of foot infection
  • Control of ischaemia
  • Wound debridement
  • Wound dressings
• Offer non-removable casting to offload plantar neuropathic, non-ischaemic, uninfected forefoot and midfoot diabetic ulcers. Offer an alternative offloading device until casting can be provided
• In line with the NICE guideline on pressure ulcers, use pressure-redistributing devices and strategies to minimise the risk of pressure ulcers developing
• When treating diabetic foot ulcers, debridement in hospital should only be done by healthcare professionals from the multidisciplinary foot care service, using the technique that best matches their specialist expertise and clinical experience, the site of the diabetic foot ulcer and the person’s preference
• When treating diabetic foot ulcers, debridement in the community should only be done by healthcare professionals with the relevant training and skills, continuing the care described in the person’s treatment plan
• Consider negative pressure wound therapy after surgical debridement for diabetic foot ulcers, on the advice of the multidisciplinary foot care service
• When deciding about wound dressings and offloading when treating diabetic foot ulcers, take into account the clinical assessment of the wound and the person’s preference, and use devices and dressings with the lowest acquisition cost appropriate to the clinical circumstances
• Consider dermal or skin substitutes as an adjunct to standard care when treating diabetic foot ulcers, only when healing has not progressed and on the advice of the multidisciplinary foot care service
• Do not offer the following to treat diabetic foot ulcers, unless as part of a clinical trial:
  • Electrical stimulation therapy, autologous platelet-rich plasma gel, regenerative wound matrices and dalteparin
  • Growth factors (granulocyte colony-stimulating factor [G-CSF], platelet-derived growth factor [PDGF], epidermal growth factor [EGF] and transforming growth factor beta [TGF-β])
  • Hyperbaric oxygen therapy
• When deciding the frequency of follow-up as part of the treatment plan, take into account the overall health of the person with diabetes, how healing has progressed, and any deterioration. 
• Ensure that the frequency of monitoring set out in the person’s individualised treatment plan is maintained whether the person with diabetes is being treated in hospital or in the community

Diabetic foot infection

Investigation

• If a diabetic foot infection is suspected and a wound is present, send a soft tissue or bone sample from the base of the debrided wound for microbiological examination. If this cannot be obtained, take a deep swab because it may provide useful information on the choice of antibiotic treatment
• Consider an X-ray of the person’s affected foot (or feet) to determine the extent of the diabetic foot problem
• Think about osteomyelitis if the person with diabetes has a local infection, a deep foot wound or a chronic foot wound
• Be aware that osteomyelitis may be present in a person with diabetes despite normal inflammatory markers, X-rays or probe-to-bone testing
• If osteomyelitis is suspected in a person with diabetes but is not confirmed by initial X-ray, consider an MRI to confirm the diagnosis

Treatment

• Start antibiotic treatment for people with suspected diabetic foot infection as soon as possible. Take samples for microbiological testing before, or as close as possible to, the start of antibiotic treatment
• When choosing an antibiotic for people with a suspected diabetic foot infection (see the section on choice of antibiotic), take account of:
  • the severity of diabetic foot infection (mild, moderate or severe)
  • the risk of developing complications
  • previous microbiological results
  • previous antibiotic use
  • patient preferences

Choice of antibiotic

• When prescribing antibiotics for a suspected diabetic foot infection in adults aged 18 years and over, follow table 1 for a mild infection or table 2 for a moderate or severe infection
• Seek specialist advice when prescribing antibiotics for a suspected diabetic foot infection in children and young people under 18 years
• Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics
• If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible
• Base antibiotic course length on the severity of the infection and a clinical assessment of response to treatment. Review the need for continued antibiotics regularly

Table 1: Antibiotics for mild diabetic foot infection in adults aged 18 years and over

AntibioticA	Dosage and course lengthB
First-choice oral antibiotic
Flucloxacillin	500 mg to 1 g four times a day for 7 daysC,D
Alternative oral antibiotics for penicillin allergy or if flucloxacillin unsuitable (guided by microbiological results when available)
Clarithromycin	500 mg twice a day for 7 daysC
Erythromycin (in pregnancy)	500 mg four times a day for 7 daysC
Doxycycline	200 mg on first day, then 100 mg once a day (can be increased to 200 mg daily) for 7 daysC
A See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding. B Oral doses are for immediate-release medicines. C A longer course (up to a further 7 days) may be needed based on clinical assessment. However, skin does take some time to return to normal, and full resolution of symptoms at 7 days is not expected. D The upper dose of 1 g four times a day would be off‑label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.

Table 2: Antibiotics for moderate or severe diabetic foot infection in adults aged 18 years and over

AntibioticA	DosageB
First-choice antibiotics (guided by microbiological results when available).C,D,E In severe infection, give IV for at least 48 hours (until stabilised). Course length is based on clinical assessment: minimum of 7 days and up to 6 weeks for osteomyelitis (use oral antibiotics for prolonged treatment)F
Flucloxacillin with or without	1 g four times a day orallyG	or  1 to 2 g four times a day IV
GentamicinH,I and/or	Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted according to serum gentamicin concentration
Metronidazole	400 mg three times a day orally	or  500 mg three times a day IV
Co-amoxiclav with or without	500/125 mg three times a day orally	or  1.2 g three times a day IV
GentamicinH,I	Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted according to serum gentamicin concentration
Co-trimoxazole (in penicillin allergy)I,J with or without	960 mg twice a day orally	or  960 mg twice a day IV (can be increased to 1.44 g twice a day)
GentamicinH,I and/or	Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted according to serum gentamicin concentration
Metronidazole	400 mg three times a day orally	or  500 mg three times a day IV
Ceftriaxone with	2 g once a day IV
Metronidazole	400 mg three times a day orally	or  500 mg three times a day IV
Additional antibiotic choices if Pseudomonas aeruginosa suspected or confirmed (guided by microbiological results when available)C,D,E,K
Piperacillin with tazobactam	4.5 g three times a day IV (can be increased to 4.5 g four times a day)
Clindamycin with	150 to 300 mg four times a day orally (can be increased to 450 mg four times a day)	or  600 mg to 2.7 g daily IV in two to four divided doses, increased if necessary in life-threatening infection to 4.8 g daily (maximum per dose 1.2 g)
Ciprofloxacin (consider safety issuesL) and/or	500 mg twice a day orally	or  400 mg two or three times a day IV
GentamicinH,I	Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted according to serum gentamicin concentration
Antibiotics to be added if MRSA infection suspected or confirmed (combination therapy with an antibiotic listed above)D,E
VancomycinH,I	15 to 20 mg/kg two or three times a day IV (maximum 2 g per dose), adjusted according to serum vancomycin concentration
TeicoplaninH,I	Initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a day IV
Linezolid (if vancomycin or teicoplanin cannot be used; specialist use only)I	600 mg twice a day orally	600 mg twice a day IV
A See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics. B Oral doses are for immediate-release medicines. C Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics. D Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible. E Other antibiotics may be appropriate based on microbiological results and specialist advice. F Skin takes some time to return to normal, and full resolution of symptoms after a course of antibiotics is not expected. Review the need for continued antibiotics regularly. G The dose of 1 g four times a day would be off‑label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information. H See BNF for information on therapeutic drug monitoring. I See BNF for information on monitoring of patient parameters. J Not licensed for diabetic foot infection, so use would be off‑label (see above). K These antibiotics may also be appropriate in other situations based on microbiological results and specialist advice. L See Medicines and Healthcare Products Regulatory Agency (MHRA) advice for restrictions and precautions for using fluroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019).
Abbreviations: IV=intravenous; MRSA=meticillin-resistant Staphylococcus aureus.

Advice

• When prescribing antibiotics for a diabetic foot infection, give advice about:
  • possible adverse effects of the antibiotic(s)
  • seeking medical help if symptoms worsen rapidly or significantly at any time, or do not start to improve within 1 to 2 days

Reassessment

• When microbiological results are available:
  • review the choice of antibiotic and
  • change the antibiotic according to results, using a narrow-spectrum antibiotic, if appropriate.
• Reassess people with a suspected diabetic foot infection if symptoms worsen rapidly or significantly at any time, do not start to improve within 1 to 2 days, or the person becomes systemically very unwell or has severe pain out of proportion to the infection. Take account of:
  • other possible diagnoses, such as pressure sores, gout or non-infected ulcers
  • any symptoms or signs suggesting a more serious illness or condition, such as limb ischaemia, osteomyelitis, necrotising fasciitis or sepsis
  • previous antibiotic use

Prevention

• Do not offer antibiotics to prevent diabetic foot infections. Give advice about seeking medical help if symptoms of a diabetic foot infection develop.

Terms used in the guideline

Diabetic foot infection

• Diabetic foot infection is defined by the presence of at least 2 of the following:
  • local swelling or induration erythema
  • local tenderness or pain
  • local warmth
  • purulent discharge

Mild diabetic foot infection

• Local infection involving only the skin and subcutaneous tissue; if erythema, must be 0.5 cm to less than 2 cm around the ulcer (exclude other causes of inflammatory response, such as trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis and venous stasis).

Moderate diabetic foot infection

• 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.

Severe diabetic foot infection

• 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).

^[A] For guidance on education programmes and information about diabetes, see the education and information section in type 1 diabetes in adults: diagnosis and management (NICE guideline NG17), the patient education section in type 2 diabetes in adults: management (NICE guideline NG28) and the sections education and information for children and young people with type 1 diabetes and education and information for children and young people with type 2 diabetes in diabetes (type 1 and type 2) in children and young people: diagnosis and management (NICE guideline NG18).