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.
Rationale and impact
- A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.
- 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.
- The committee accepted the Infectious Diseases Society of America’s definitions of mild, moderate and severe infection, and recommended that this should be taken into account when choosing an antibiotic.
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.
- Diabetes is a chronic condition and people may have had previous foot infections, with previous courses of antibiotics, that will influence their preferences.
- If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.
- Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
- No evidence was identified for antibiotic prophylaxis and the committee agreed that antibiotic prophylaxis is not appropriate because of concerns about antimicrobial 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.
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It is also a chance to teach people how to look after their feet, and to emphasise the importance of doing so. Many people with diabetes do not have good foot care routines, or do not have foot care routines at all. And they may benefit from regular advice about risk factors for foot problems.
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The committee agreed that in people with diabetes, all foot wounds are likely to be colonised with bacteria. However, for people with a diabetic foot infection, prompt treatment of the infection is important to prevent complications, including limb-threatening infections. The evidence showed that 95.5% of people assessed as low risk at their first clinical assessment remained in the low-risk group at their final assessment 8 years later.
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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.
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People have the right to be involved in discussions and make informed decisions about their care, as described in NICE’s information on making decisions about your care. For information on related topics see our cardiometabolic disease prevention and treatment summary page.
Diabetic foot problems: prevention and management
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 gen z alphabet 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.
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 these 2019 recommendations and how they might affect practice, see the rationale and impact section on treatment. The 2015 guideline recommended a modified version of SIGN that includes a check for renal disease. The committee agreed that this modification is useful and should be retained, because renal disease is a known risk factor for diabetic foot problems. 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 advice. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. This guideline updates and replaces NICE guidelines CG10 (January 2004) and CG119 (March 2011), and the recommendation on foot care in NICE guideline CG15 (July 2004).
Guideline development process
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.