Red Flags
- Severe diabetes-related foot infection (systemic toxicity, deep ulcer to bone, gas in tissues, rapid spread) — admit; broad-spectrum IV antibiotics; surgical debridement[1]
- Critical limb ischaemia with diabetic foot ulcer (rest pain, ankle pressure <50 mmHg) — vascular emergency; revascularisation may save limb[1]
- Probe-to-bone positive ulcer or X-ray bone changes — likely osteomyelitis; bone biopsy and prolonged targeted antibiotics[1]
- Charcot neuroarthropathy — acute red, hot, swollen foot in diabetic neuropathy without infection; total contact cast off-loading; orthopaedic referral[1]
First-line treatment
Interventions
- Off-loading (gold standard: total contact cast)[1]Plantar diabetic foot ulcers heal only when off-loaded. Total contact cast or removable cast walker rendered irremovable; bed rest insufficient
- Surgical debridement[1]Sharp debridement of necrotic tissue; major surgical debridement for severe infection or osteomyelitis; minor amputation to salvage limb when feasible
- Glycaemic and risk-factor control[1]Optimise HbA1c; smoking cessation; statin and antiplatelet for ASCVD; structured diabetes self-management education
- Multidisciplinary diabetic foot team[1]Endocrinology + podiatry + vascular surgery + infectious diseases + diabetic foot nurse — reduces amputation rates 50–70%
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Cephalexin or amoxicillin-clavulanate (mild infection)[1] | Beta-lactam (oral) | Cephalexin 500 mg PO QID OR amox-clav 875/125 mg PO BD × 7–10 days | Weight-based | Mild, superficial infection without bone involvement; cover Staph aureus and streptococci |
| Piperacillin-tazobactam or ertapenem (moderate-severe)[1] | Broad-spectrum beta-lactam | Piperacillin-tazobactam 4.5 g IV q8h OR ertapenem 1 g IV daily; 10 days for moderate/severe soft-tissue (per 2023 update — shorter than older 14-day default) | — | Polymicrobial cover including Gram-negatives and anaerobes; add vancomycin or linezolid if MRSA risk (prior colonisation, severe infection, prevalent locally) |
| Targeted IV antibiotic for osteomyelitis[1] | Bone-penetrating regimen | Per culture and sensitivity; typical: cefazolin or ceftriaxone for MSSA; vancomycin for MRSA; ciprofloxacin + clindamycin or rifampicin combination | — | 6 weeks for osteomyelitis (parenteral with step-down to oral); follow-up to 6 months to define remission |
Cephalexin or amoxicillin-clavulanate (mild infection)[1]
Beta-lactam (oral)
- Adult
- Cephalexin 500 mg PO QID OR amox-clav 875/125 mg PO BD × 7–10 days
- Paediatric
- Weight-based
Mild, superficial infection without bone involvement; cover Staph aureus and streptococci
Piperacillin-tazobactam or ertapenem (moderate-severe)[1]
Broad-spectrum beta-lactam
- Adult
- Piperacillin-tazobactam 4.5 g IV q8h OR ertapenem 1 g IV daily; 10 days for moderate/severe soft-tissue (per 2023 update — shorter than older 14-day default)
- Paediatric
- —
Polymicrobial cover including Gram-negatives and anaerobes; add vancomycin or linezolid if MRSA risk (prior colonisation, severe infection, prevalent locally)
Targeted IV antibiotic for osteomyelitis[1]
Bone-penetrating regimen
- Adult
- Per culture and sensitivity; typical: cefazolin or ceftriaxone for MSSA; vancomycin for MRSA; ciprofloxacin + clindamycin or rifampicin combination
- Paediatric
- —
6 weeks for osteomyelitis (parenteral with step-down to oral); follow-up to 6 months to define remission
Safety-net
- Inspect feet daily — look for redness, swelling, blisters, cuts, especially between toes; report new lesions same week[1]
- Never walk barefoot; check shoes for foreign bodies before wearing; trim toenails straight across[1]
- Sudden severe foot pain, fever, or rapidly spreading redness — same-day care; can be limb-threatening[1]
Referral criteria
- Severe diabetic foot infection or critical limb ischaemiaEmergency department; multidisciplinary diabetic foot team[1]
- Suspected osteomyelitis (probe-to-bone, X-ray bone changes, non-healing ulcer >6 weeks)Diabetic foot service for MRI, bone biopsy, and prolonged targeted therapy[1]
- Acute Charcot neuroarthropathyOrthopaedic / diabetic foot service for total contact casting[1]
- PAD on screening (ABI <0.9 or absent pulses)Vascular surgery for revascularisation evaluation[1]
Clinical summary
Prevention, infection management, and offloading of diabetic foot disease per IWGDF/IDSA 2023; risk-stratified surveillance, multidisciplinary care.