| 1. Determine the presence of infection based on signs and symptoms of local inflammation in every diabetic patient with foot ulcers. |
Class I/level of evidence C158-162
|
| 2. Use the Infectious Diseases Society of America classification system to stratify severity. |
Class I/level of evidence B90,163,164
|
| 3. Use CRP, ESR, or procalcitonin measurement in cases of diagnostic uncertainty. |
Class IIb/level of evidence C165-170
|
| 4. Use plain radiography, the probe-to-bone test, and ESR measurement to diagnose osteomyelitis. |
Class I/level of evidence B171-175
|
| 5. Request MRI (preferably) or PET-CT/scintigraphy with marked leukocytes to diagnose osteomyelitis only if there is diagnostic uncertainty after initial evaluation. |
Class I/level of evidence B176-180
|
| 6. Collect cultures aseptically to determine the pathogen involved in all infected diabetic foot ulcers. |
Class I/level of evidence C145,181-183
|
| 7. Collect bone cultures (surgically or percutaneously) to identify the pathogen in cases of osteomyelitis, especially when empirical treatment has failed or there is a high probability of osteomyelitis and diagnostic uncertainty after imaging tests. |
Class IIa/level of evidence C145,181-183
|
| 8. Use antibiotic therapy to treat infected diabetic foot ulcers according to the sensitivity profile of the likely pathogens involved, infection severity, and previous antibiotic use. |
Class I/level of evidence B184-190
|
| 9. Start parenteral antibiotic therapy in cases of severe infection; the treatment can be changed to an oral regimen after clinical improvement and when feasible from the point of view of tolerance and bioavailability. |
Class IIa/level of evidence C188-190
|
| 10. Do not use topical antibiotics to treat wound infections. |
Class III/level of evidence B191,192
|
| 11. Administer antibiotics for 1-2 weeks for soft tissue infection and 3-4 weeks for improving extensive lesions and/or concurrent severe PAD, which may prolong the healing period. |
Class IIa/level of evidence C189,190,193-195
|
| 12. Administer antibiotics for ≤ 6 weeks in cases of osteomyelitis, evaluating the results in the first 2 to 4 weeks, considering new collection or treatment adjustment according to the culture results. |
Class IIa/level of evidence B196-198
|
| 13. Administer a spectrum of antibiotics for the most prevalent gram-positive and gram-negative lesions in cases of PAD, previous antibiotic use, or moderate/severe lesions. Add strict anaerobe coverage for moderate/severe cases and consider adding coverage for Pseudomonas aeruginosa. |
Class IIa/level of evidence C189-195,199
|
| 14. Reevaluate and adjust antibiotic therapy according to the culture sensitivity results; do not use antimicrobials in non-infected wounds to avoid infection or accelerate healing. |
Class I/level of evidence C200,201
|
| 15. Consider reevaluating treatment and collecting new cultures if treatment fails after the expected time. |
Class IIb/level of evidence C13
|
| 16. Osteomyelitis treatment may not involve surgical resection of the bone when limited to the forefoot. In other cases, consider surgical resection, especially when there is associated soft tissue infection. |
Class IIb/level of evidence B201-207
|
| 17. During surgical bone resection, we suggest collecting a fragment of the remaining bone portion for culture and residual infection assessment. |
Class IIb/level of evidence C208-211
|
| 18. Antibiotic treatment for osteomyelitis can be shortened if the entire focus is removed from the bone and the residual fragment culture is negative. If the culture is positive, continue treatment for 6 weeks. |
Class IIb/level of evidence C208-211
|
| 19. Do not use hyperbaric oxygen therapy, topical oxygen therapy, routine topical antiseptics, silver preparations, or negative pressure therapy to treat ulcers if the only recommendation is to treat infection. |
Class III/level of evidence B212-215
|
Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot
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