Diagnosis and Treatment of Diabetes-related Foot Infections

Publication Date: October 2, 2023
Last Updated: October 10, 2023

List of Recommendations

Diagnose a soft tissue diabetes-related infection clinically based on the presence of local or systemic signs and symptoms of inflammation. (S, L)

Asses the severity of any Diabetes-related foot infection (DFI) using the International Working Group on the Diabetic Foot (IWGDF)/Infectious Diseases Society of America (IDSA) classification scheme. (S, L)

Consider hospitalising all persons with diabetes and a foot infection who have either a severe foot infection as classified by the IWGDF/IDSA classification or a moderate infection which is associated with key relevant morbidities. (C, L)

Assess inflammatory serum biomarkers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), or procalcitonin (PCT) in a person with diabetes and a possible infected foot ulcer for whom the clinical examination is diagnostically equivocal or uninterpretable. (U, U)

For diagnosing diabetes-related foot soft-tissue infection, we suggest not using foot temperature (however measured) or quantitative microbial analysis. (C, L)

In a person with suspected soft tissue DFI, consider a sample for culture to determine the causative microorganisms, preferably by aseptically collecting a tissue specimen (by curettage or biopsy) from the wound. (C, M)

Use conventional, rather than molecular, microbiology techniques for the first-line identification of pathogens from soft tissue or bone samples in a patient with a DFI. (S, M)

In a person with diabetes, consider using a combination of probe-to-bone test, plain X-rays, and ESR, or CRP, or PCT as the initial studies to diagnose osteomyelitis of the foot. (C, L)

Perform magnetic resonance imaging (MRI) when the diagnosis of diabetes-related osteomyelitis of the foot remains in doubt despite clinical, plain X-rays and laboratory findings. (S, M)

Consider using positron emission tomography (PET), leucocyte scintigraphy, or single photon emission computed tomography (SPECT) as an alternative to MRI for the diagnosis of diabetes-related osteomyelitis of the foot. (C, L)

In a person with diabetes for whom there is a suspicion of osteomyelitis of the foot (before or after treatment), bone (rather than soft tissue) samples should be obtained for culture, either intraoperatively or percutaneously. (C, M)

Do not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy when the goal is to reduce the risk of new infection or to promote ulcer healing. (U, U)

Use any of the systemic antibiotic regimens that have been shown to be effective in published randomised controlled trials at standard (usual) dosing to treat a person with diabetes and a soft tissue infection of the foot. (S, H)

Administer antibiotic therapy to a patient with a skin or soft tissue diabetic foot infection for a duration of 1–2 weeks. (S, H)

Consider continuing treatment, perhaps for up to 3–4 weeks, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease (PAD). (C, L)

If evidence of infection has not resolved after 4 weeks of apparently appropriate therapy, re-evaluate the patient, and reconsider the need for further diagnostic studies or alternative treatments. (S, L)

Select an antibiotic agent for treating a DFI based on the likely or proven causative pathogen(s) and their antibiotic susceptibilities; the clinical severity of the infection; published evidence of the efficacy of the agent for infections of the diabetes-related foot; the risk of adverse events including collateral damage to the commensal flora; the likelihood of drug interactions; agent availability and costs. (U, U)

Target aerobic gram-positive pathogens only (beta-haemolytic streptococci and Staphylococcus aureus including methicillin-resistant strains if indicated) for people with a mild DFI, who have not recently received antibiotic therapy, and who reside in North America or Western Europe. (U, U)

Do not empirically target antibiotic therapy against Pseudomonas aeruginosa in cases of DFI in temperate climates, but use empirical treatment of P. aeruginosa if it has been isolated from cultures of the affected site within the previous few weeks, in a person with moderate or severe infection who resides in Asia or North Africa. (U, U)

Consider a duration of up to 3 weeks of antibiotic therapy after minor amputation for diabetes-related osteomyelitis of the foot and positive bone margin culture and 6 weeks for diabetes-related foot osteomyelitis without bone resection or amputation. (C, L)

Use the outcome at a minimum follow-up duration of 6 months after the end of the antibiotic therapy to diagnose remission of diabetes-related osteomyelitis of the foot. (U, U)

The urgent surgical consultation should be obtained in cases of severe infection or moderate DFI complicated by extensive gangrene, necrotising infection, signs suggesting deep (below the fascia) abscess, compartment syndrome, or severe lower limb ischaemia. (U, U)

Consider performing early (within 24–48 h) surgery combined with antibiotics for moderate and severe DFIs to remove the infected and necrotic tissue. (C, L)

In people with diabetes, PAD and a foot ulcer or gangrene with infection involving any portion of the foot obtain an urgent consultation by a surgical specialist as well as a vascular specialist in order to determine the indications and timings of a drainage and/or revascularisation procedure. (U, U)

Consider performing surgical resection of infected bone combined with systemic antibiotics in a person with diabetes-related osteomyelitis of the foot. (C, L)

Consider antibiotic treatment without surgery in case of (i) forefoot osteomyelitis without an immediate need for incision and drainage to control infection, (ii) without PAD, and (iii) without exposed bone. (C, L)

We suggest not using the following treatments to address DFIs: (a) adjunctive granulocyte colony-stimulating factor (G-CSF) treatment or (b) topical antiseptics, silver preparations, honey, bacteriophage therapy, or negative-pressure wound therapy (with or without instillation). (C, L)

We suggest not using topical (sponge, cream, and cement) antibiotics in combination with systemic antibiotics for treating either soft-tissue infections or osteomyelitis of the foot in patients with diabetes. (C, L)

We suggest not using Hyperbaric oxygen (HBO) therapy or topical oxygen therapy as an adjunctive treatment for the sole indication of treating a DFI. (C, L)

Recommendation Grading


  • CRP: C-reactive Protein
  • DFI: Diabetic Foot Infection
  • ESR: Erythrocyte Sedimentation Rate
  • G-CSF: Granulocyte Colony-stimulating Factor
  • HBO: Hyperbaric Oxygen
  • IDSA: Infectious Diseases Society Of America
  • IWGDF: International Working Group On The Diabetic Foot
  • MRI: Magnetic Resonance Imaging
  • PAD: Peripheral Artery Disease
  • PCT: Procalcitonin
  • PET: Positron Emission Tomography
  • SPECT: Single Photon Emission Computed Tomography


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.



Diagnosis and Treatment of Diabetes-related Foot Infections

Authoring Organizations

Publication Month/Year

October 2, 2023

Last Updated Month/Year

November 2, 2023

Document Type


Country of Publication


Document Objectives

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant, podiatrist


Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D017719 - Diabetic Foot


diabetic foot infection, diabetic foot, DFI

Source Citation

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, https://doi.org/10.1093/cid/ciad527