Managing a diabetic foot problem

NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/foot-care-for-people-with-diabetes
NICE Pathway last updated: 10 October 2019

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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 Managing a diabetic foot problem NICE Pathways

Foot care for people with diabetes Page 2 of 18

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 Managing a diabetic foot problem NICE Pathways

1 Child, young person or adult with a diabetic foot problem

No additional information

2 When to refer

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; also see principles of care), 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 (see what NICE says on sepsis).
Ulceration with limb ischaemia (see what NICE says on lower limb 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; also see principles of care) for triage within 1 further working day.

Be aware that if a person with diabetes fractures their foot or ankle, it may progress to Charcot
arthropathy.

Suspect acute Charcot arthropathy if there is redness, warmth, swelling or deformity (in
particular, when the skin is intact), especially in the presence of peripheral neuropathy or renal
failure. Think about acute Charcot arthropathy even when deformity is not present or pain is not
reported.

To confirm the diagnosis of acute Charcot arthropathy, refer the person within 1 working day to
the multidisciplinary foot care service for triage within 1 further working day. Offer non-weight-
bearing treatment until definitive treatment can be started by the multidisciplinary foot care
service.

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 Managing a diabetic foot problem NICE Pathways

Referral in hospital

Refer the person to the multidisciplinary foot care service within 24 hours of the initial
examination of the person's feet. Transfer the responsibility of care to a consultant member of
the multidisciplinary foot care service if a diabetic foot problem is the dominant clinical factor for
inpatient care.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

6. Referral for urgent diabetic foot problems

3 Patient information

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 (also see patient
information and support).

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 what NICE
says on cardiovascular disease prevention.

NICE has written information for the public on diabetic foot problems.

4 Charcot arthropathy

No additional information

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 Managing a diabetic foot problem NICE Pathways

5 Investigation

If acute Charcot arthropathy is suspected, arrange a weight-bearing X-ray of the affected foot
and ankle. Consider an MRI if the X-ray is normal but Charcot arthropathy is still suspected.

6 Treatment

If the multidisciplinary foot care service suspects acute Charcot arthropathy, offer treatment with
a non-removable offloading device. If a non-removable device is not advisable because of the
clinical, or the person's, circumstances, consider treatment with a removable offloading device.

Do not offer bisphosphonates to treat acute Charcot arthropathy, unless as part of a clinical trial.

Monitor the treatment of acute Charcot arthropathy using clinical assessment. This should
include measuring foot–skin temperature difference and taking serial X-rays until the acute
Charcot arthropathy resolves. Acute Charcot arthropathy is likely to resolve when there is a
sustained temperature difference of less than 2 degrees between both feet and when X-ray
changes show no further progression.

People who have a foot deformity that may be the result of a previous Charcot arthropathy are
at high risk of ulceration and should be cared for by the foot protection service.

7 Diabetic foot infection

No additional information

8 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.

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 Managing a diabetic foot problem NICE Pathways

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.

9 Antibiotic 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
recommendations below) 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.

When prescribing antibiotics for a suspected diabetic foot infection in adults aged 18 years and
over, follow the tables on antibiotics for mild diabetic foot infection [See page 11] or antibiotics
for moderate or severe diabetic foot infection [See page 12].

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.

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 Managing a diabetic foot problem NICE Pathways

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.

When microbiological results are available:

review the choice of antibiotic and

change the antibiotic according to results, using a narrow-spectrum antibiotic, if appropriate.

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

NICE has produced a visual summary on antimicrobial prescribing for diabetic foot infection.

See what NICE says on antimicrobial stewardship.

Rationale and impact

See the NICE guideline to find out why we made these recommendations and how they might
affect practice.

10 When to reassess

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.

NICE has produced a visual summary on antimicrobial prescribing for diabetic foot infection.

See the NICE guideline to find out why we made this recommendation and how it might affect
practice.

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 Managing a diabetic foot problem NICE Pathways

11 Diabetic foot ulcer

No additional information

12 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.

13 Treatment

Offer 1 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 NICE's recommendations 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

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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.

UrgoStart for treating diabetic foot ulcers and leg ulcers

The following recommendations are from NICE medical technologies guidance on UrgoStart for
treating diabetic foot ulcers and leg ulcers.

Evidence supports the case for adopting UrgoStart dressings to treat diabetic foot ulcers and
venous leg ulcers in the NHS, because they are associated with increased wound healing
compared with non-interactive dressings.

UrgoStart dressings should therefore be considered as an option for people with diabetic foot
ulcers or venous leg ulcers after any modifiable factors such as infection have been treated.

Cost modelling shows that, compared with standard care, using UrgoStart dressings to treat

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 Managing a diabetic foot problem NICE Pathways

diabetic foot ulcers is associated with a cost saving of £342 per patient after 1 year. It also
shows that UrgoStart is likely to be cost saving for treating venous leg ulcers, but the
robustness of this conclusion is less certain from the evidence available. For both types of
ulcers, potential cost savings mainly come from better healing with UrgoStart dressings. If 25%
of people having treatment for diabetic foot ulcers use UrgoStart instead of a non-interactive
dressing, the NHS may save up to £5.4 million each year. For more details, see NICE's
resource impact report.

For people with non-venous leg ulcers, there is insufficient evidence to support routine adoption.

The Debrisoft monofilament debridement pad for use in acute or chronic wounds

The following recommendations are from NICE medical technologies guidance on the Debrisoft
monofilament debridement pad for use in acute or chronic wounds.

The case for adopting the Debrisoft monofilament debridement pad as part of the management
of acute or chronic wounds in the community is supported by the evidence. The available
evidence is limited, but the likely benefits of using the Debrisoft pad on appropriate wounds are
that they will be fully debrided more quickly, with fewer nurse visits needed, compared with other
debridement methods. In addition, the Debrisoft pad is convenient and easy to use, and is well
tolerated by patients. Debridement is an important component of standard woundcare
management as described in this NICE Pathway and NICE's recommendations on pressure
ulcers.

The Debrisoft pad is indicated for adults and children with acute or chronic wounds. The
available evidence is mainly in adults with chronic wounds needing debridement in the
community. The data show that the device is particularly effective for chronic sloughy wounds
and hyperkeratotic skin around acute or chronic wounds.

The Debrisoft pad is estimated to be cost saving for complete debridement compared with other
debridement methods. When compared with hydrogel, gauze and bagged larvae, cost savings
per patient (per complete debridement) are estimated to be £99, £154 and £373 respectively in
a community clinic and £213, £292 and £277 respectively in the home.

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Managing a diabetic foot problem NICE Pathways

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

Antibiotic1 Dosage and course length2

First-choice oral antibiotic

Flucloxacillin 500 mg to 1 g four times a day for 7 days3,4

Alternative oral antibiotics for penicillin allergy or if flucloxacillin unsuitable (guided by

microbiological results when available)

Clarithromycin 500 mg twice a day for 7 days3

Erythromycin (in
500 mg four times a day for 7 days3
pregnancy)

200 mg on first day, then 100 mg once a day (can be increased to 200
Doxycycline
mg daily) for 7 days3

1
See BNF for appropriate use and dosing in specific populations, for example, hepatic
impairment, renal impairment, pregnancy and breastfeeding.

2
Oral doses are for immediate-release medicines.

3
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.

4
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

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Managing a diabetic foot problem NICE Pathways

prescribing and managing medicines and devices for further information.

Antibiotics for moderate or severe diabetic foot infection in adults aged 18

years and over

Antibiotic1 Dosage2

First-choice antibiotics (guided by microbiological results when available).3,4,5 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)6

Flucloxacillin with or 1 g four times a day

or 1 to 2 g four times a day IV
without orally7

Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted

Gentamicin8,9 and/or
according to serum gentamicin concentration

400 mg three times a

Metronidazole or 500 mg three times a day IV
day orally

Co-amoxiclav with or 500/125 mg three times

or 1.2 g three times a day IV
without a day orally

Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted

Gentamicin8,9
according to serum gentamicin concentration

Co-trimoxazole (in
960 mg twice a day or 960 mg twice a day IV (can be increased
penicillin allergy)9,10
orally to 1.44 g twice a day)
with or without

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Managing a diabetic foot problem NICE Pathways

Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted

Gentamicin8,9 and/or
according to serum gentamicin concentration

400 mg three times a

Metronidazole or 500 mg three times a day IV
day orally

Ceftriaxone with 2 g once a day IV

400 mg three times a

Metronidazole or 500 mg three times a day IV
day orally

Additional antibiotic choices if Pseudomonas aeruginosa suspected or confirmed

(guided by microbiological results when available)3,4,5,11

Piperacillin with
4.5 g three times a day IV (can be increased to 4.5 g four times a day)
tazobactam

150 to 300 mg four or 600 mg to 2.7 g daily IV in two to four

times a day orally (can divided doses, increased if necessary in
Clindamycin with
be increased to 450 mg life-threatening infection to 4.8 g daily
four times a day) (maximum per dose 1.2 g)

Ciprofloxacin
500 mg twice a day
(consider safety or 400 mg two or three times a day IV
orally
issues12) and/or

Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted

Gentamicin8,9
according to serum gentamicin concentration

Antibiotics to be added if MRSA infection suspected or confirmed (combination therapy

with an antibiotic listed above)4,5

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Managing a diabetic foot problem NICE Pathways

15 to 20 mg/kg two or three times a day IV (maximum 2 g per dose),

Vancomycin8,9
adjusted according to serum vancomycin concentration

Initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a
Teicoplanin8,9
day IV

Linezolid (if
vancomycin or
600 mg twice a day
teicoplanin cannot be 600 mg twice a day IV
orally
used; specialist use
only)9

1
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.

2
Oral doses are for immediate-release medicines.

3
Give oral antibiotics first line if the person can take oral medicines, and the severity of their
condition does not require intravenous antibiotics.

4
Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if
possible.

5
Other antibiotics may be appropriate based on microbiological results and specialist advice.

6
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.

7
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.

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Managing a diabetic foot problem NICE Pathways

8
See BNF for information on therapeutic drug monitoring.

9
See BNF for information on monitoring of patient parameters.

10
Not licensed for diabetic foot infection, so use would be off-label (see above).

11
These antibiotics may also be appropriate in other situations based on microbiological
results and specialist advice.

12
See 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).

Glossary

Diabetic foot infection

(defined by the presence of at least 2 of the following: local swelling or induration, erythema,
local tenderness or pain, local warmth, purulent discharge)

IV

(intravenous)

Mild

(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

(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],

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Managing a diabetic foot problem NICE Pathways

and no systemic inflammatory response signs)

MRSA

(meticillin resistant Staphylococcus aureus)

Off-label

(a medicine with an existing UK marketing authorisation that is used outside the terms of its
marketing authorisation, for example, by indication, dose, route or patient population)

Severe

(local infection with signs of systemic inflammatory response [such as temperature more than
38°C or less than 36°C, increased heart rate or increased respiratory rate])

Sources

Diabetic foot problems: prevention and management (2015 updated 2019) NICE guideline
NG19

UrgoStart for treating diabetic foot ulcers and leg ulcers (2019) NICE medical technologies
guidance 42

The Debrisoft monofilament debridement pad for use in acute or chronic wounds (2014,
updated 2019) NICE medical technologies guidance 17

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them

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Managing a diabetic foot problem NICE Pathways

and their families and carers or guardian.

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. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

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.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

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.

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Managing a diabetic foot problem NICE Pathways

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

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.

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