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IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes‐related foot infections (IWGDF/IDSA 2023)
Open accessAbstract
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. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient‐important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes‐related foot care to inform clinical care around patient‐important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes‐related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes‐related foot disease.
Overview
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TL;DR
This 2023 IWGDF/IDSA guideline updates recommendations for diagnosing and treating diabetes-related foot infections using GRADE, informed by updated systematic reviews that identified 149 studies (62 new). It emphasizes clinical diagnosis and severity classification, appropriate culture and imaging, pathogen-directed antibiotic therapy, and recommends against several adjunctive or topical treatments.
Key findings
- Diagnosis: diagnose soft-tissue infection clinically and assess severity with the IWGDF/IDSA classification (Strong; Low); consider tissue specimen culture rather than swab (Conditional; Moderate); use conventional rather than molecular microbiology first-line (Strong; Moderate); for osteomyelitis, consider probe-to-bone plus plain X-rays and ESR/CRP/PCT initially (Conditional; Low), MRI if doubt remains (Strong; Moderate), and bone rather than soft-tissue samples for culture (Conditional; Moderate).
- Treatment: for soft-tissue DFI, use any systemic regimen shown effective in RCTs at standard dosing (Strong; High) for 1–2 weeks (Strong; High), possibly up to 3–4 weeks if extensive and resolving slowly or with severe PAD (Conditional; Low); do not treat clinically uninfected ulcers with antibiotics to reduce infection risk or promote healing (Best Practice Statement).
- Osteomyelitis: consider up to 3 weeks of antibiotics after minor amputation with positive bone margin culture and 6 weeks without bone resection or amputation (Conditional; Low); consider surgical resection with systemic antibiotics (Conditional; Low) or antibiotics without surgery for selected forefoot osteomyelitis without immediate drainage need, PAD, or exposed bone (Conditional; Low).
- Adjunctive/topical: suggest not using G-CSF, topical antiseptics, silver preparations, honey, bacteriophage therapy, or negative-pressure wound therapy (Conditional; Low); not using topical antibiotics with systemic antibiotics (Conditional; Low); and not using HBO or topical oxygen therapy solely to treat a DFI (Conditional; Low).
Methods
- GRADE framework was used, structured around P(A)ICO questions, patient-important outcomes, systematic review of evidence, certainty assessment, and moving from evidence to recommendations; a multidisciplinary IWGDF/IDSA working group developed the guideline.
- Two 2019 systematic reviews were updated; 149 studies (62 new) meeting inclusion criteria were identified and incorporated; reviews followed PRISMA and protocols were registered in PROSPERO (CRD42022324795, CRD42022324812).
- Recommendations were discussed and voted on, with a 60% quorum required and majority vote for final decisions; strength was rated strong or conditional and certainty high, moderate, low, or very low.
Limitations
- The paper states many recommendations are conditional with low certainty, and evidence was limited by high risk of bias, inconsistency, imprecision, indirectness, and lack of a definitive criterion standard.
- The paper identifies areas with absent or inconsistent evidence, including rifampicin for diabetes-related foot osteomyelitis, bioactive glass, new antibiotics, molecular microbiology’s impact on management, optimal antibiotic durations, and whether bone biopsy improves outcomes.
- Evident from the text: this is a guideline based on systematic reviews and expert consensus rather than new primary data; the data availability statement says no new data were created or analyzed.
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“However, there is no convincing data (from studies using either conventional culture or molecular methods) supporting this concept.72”
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“While various imaging tests are widely used for diagnosing bone infection (see below), there are few data on their usefulness for softtissue infections.”
§ IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023) > Rationale
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“Due to their limited specificity and sensitivity, not exceeding 0.85, when used as sole diagnostic tools, inflammatory biomarkers should be used when uncertainty persists after clinical assessment.”
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“Insufficient quality of evidence led us to not consider either laboratory risk indicators for necrotising fasciitis or SIRS as reliable tools for predicting lower extremity amputation, mortality, or other health outcomes.52,53”
§ IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023) > Rationale
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“However, there are no data to support changing from using the systemic inflammatory response syndrome (SIRS) that is part of the IWGDF/IDSA classification to any other classification for DFIs.”
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§ IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023) > Rationale
“Class 3/4: Moderate/severe Oral/initially iv 2-4 weeks”
§ IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023) > CONFLICT OF INTEREST STATEMENT
“Administer antibiotic therapy to a patient with a skin or soft tissue diabetic foot infection for a duration of 1-2 weeks.(Strong; High).”
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Pham, T., Wetzel, O., Gariani, K., Kressmann, B., Jornayvaz, F. R., Lipsky, B. A., & Uçkay, İ. (2020) · Diabetes Obesity and Metabolism · doi:10.1111/dom.14222 · Cited by 12
Self-citationLipof, J. S., Jones, C. M. C., Daiss, J. L., & Oh, I. C. (2021) · Journal of Orthopaedic Research® · doi:10.1002/jor.25001 · Cited by 12
Çildağ, M. B., Ertuğrul, B., Köseoğlu, Ö. F., & Armstrong, D. G. (2018) · Journal of Clinical Imaging Science · doi:10.4103/jcis.jcis_77_17 · Cited by 10
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Role of Inflammatory Markers in Diagnosing Diabetic Foot Infection: A Meta-Analysis
Majeed, A., Mushtaq, A., Iftikhar, A., Zahid, U., Malik, M. N., Razzaq, F., & Mohajer, M. A. (2019) · Infectious Diseases in Clinical Practice · doi:10.1097/ipc.0000000000000763 · Cited by 9
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Do SIRS Criteria Predict Clinical Outcomes in Diabetic Skin and Soft Tissue Infections?
Ryan, E. C., Crisologo, P. A., Öz, O. K., Fontaine, J. L., Wukich, D. K., & Lavery, L. A. (2019) · The Journal of Foot & Ankle Surgery · doi:10.1053/j.jfas.2019.06.001 · Cited by 8
Self-citationMicrobiological evaluation of resection margins of the infected diabetic foot ulcer
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Research works printed but not linked: 7
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Cited by
Schaper, N. C., van Netten, J. J., Apelqvist, J., Bus, S. A., Fitridge, R., Game, F., Monteiro‐Soares, M., Senneville, E., & the IWGDF Editorial Board (2024) · Diabetes/Metabolism Research and Reviews · doi:10.1002/dmrr.3657 · Cited by 583
Self-citationGuidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update)
Bus, S. A., Sacco, I. C. N., Monteiro‐Soares, M., Raspovic, A., Paton, J., Rasmussen, A., Lavery, L. A., & van Netten, J. J. (2024) · Diabetes/Metabolism Research and Reviews · doi:10.1002/dmrr.3651 · Cited by 279
Self-citationChen, P., Vilorio, N. C., Dhatariya, K., Jeffcoate, W., Lobmann, R., McIntosh, C., Piaggesi, A., Steinberg, J., Vas, P., Viswanathan, V., et al. (2024) · Diabetes/Metabolism Research and Reviews · doi:10.1002/dmrr.3644 · Cited by 246
Fitridge, R., Chuter, V., Mills, J., Hinchliffe, R., Azuma, N., Behrendt, C., Boyko, E. J., Conte, M. S., Humphries, M., Kirksey, L., et al. (2024) · Diabetes/Metabolism Research and Reviews · doi:10.1002/dmrr.3686 · Cited by 201
12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes—2026
Bajaj, M. S., McCoy, R. G., Balapattabi, K., Bannuru, R. R., Bellini, N. J., Bennett, A. K., Beverly, E. A., Early, K. B., Callaghan, B. C., ChallaSivaKanaka, S., et al. (2025) · Diabetes Care · doi:10.2337/dc26-s012 · Cited by 175
Metadata
- Authors
- Senneville, É., Albalawi, Z., van Asten, S. A., Abbas, Z. G., Allison, G., Aragón‐Sánchez, J., Embil, J. M., Lavery, L. A., Alhasan, M., Oz, O., Uçkay, I., Urbančič‐Rovan, V., Xu, Z., & Peters, E. J. G.
- Affiliations
- Université de Lille (FR)
- Memorial University of Newfoundland (CA)
- Leiden University (NL)
- Muhimbili University of Health and Allied Sciences (TZ)
- Tufts Medical Center (US)
- Hospital La Paloma (ES)
- University of Manitoba (CA)
- The University of Texas Southwestern Medical Center (US)
- Department of Medicine Prisma Health‐Midlands Columbia South Carolina USA
- UT Southwestern Medical Center Dallas Texas USA
- Balgrist University Hospital Zurich Switzerland
- University of Ljubljana (SI)
- Diabetes Centre Beijing China
- Amsterdam University Medical Centers (NL)
- Corresponding author
- Senneville, Éric
- ORCID
- Venue
- Diabetes/Metabolism Research and Reviews
- Publisher
- Wiley
- Published
- 2023-10
- Volume
- 40
- Issue
- 3
- Pages
- e3687-e3687
- ISSN
- 1520-7552 (ISSN-L)
- 1520-7560
- OpenAlex
- W4387241578
- Cited by
- 498
- References
- 172
- Citations by year
- 2026: 266 · 2025: 176 · 2024: 47 · 2023: 9
- FWCI
- 14.75
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Diabetes/Metabolism Research and Reviews (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, other-oa)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, cc-by-nc-nd)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, cc-by)
- Leiden Repository (Leiden University) (submittedVersion, cc-by)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, cc-by)
- Zurich Open Repository and Archive (University of Zurich)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetic Foot Ulcer Assessment and Management
- Health Sciences › Medicine › Surgery › Orthopedic Infections and Treatments
- Health Sciences › Medicine › Dermatology › Skin Diseases and Diabetes
- Keywords
- diabetic foot, soft tissue infection, bone infection, infection severity classification, microbiological sampling, antimicrobial therapy, empirical treatment, surgical treatment, adjunctive therapy, limb amputation prevention, foot care
- MeSH terms
- Communicable Diseases, Diabetes Mellitus, Foot, Humans, Diabetic Foot
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-11-13, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-11-13 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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Data sources
Bibliographic data: Semantic Scholar, OpenAlex, Crossref.
Contains information from the Semantic Scholar Academic Graph Datasets, made available under the ODC Attribution License (ODC-BY 1.0).
Semantic Scholar’s data is described in: Kinney, R., et al. (2023). The Semantic Scholar Open Data Platform. arXiv:2301.10140.
