These recommendations should ensure that appropriate reassessment is in place. But the antibiotics used in the studies were not wholly representative of UK practice, with some not being available in the UK and others not widely used. However, there were differences between some antibiotic classes, with lower rates of adverse effects generally for beta-lactam antibiotics. 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), and no systemic inflammatory response signs.
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.
Evidence summaries (
For information about individual topics, including any decisions affecting this guideline, see the summary table of prioritisation board decisions. Start by checking that Apple Music is installed on your smartphone or iPad and that you have an active Apple Music subscription. Then simply download and install the Apple Music Classical app on the same device and you’re all set. The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions. The recommendations aim to optimise antibiotic use and reduce antibiotic resistance.
Rationale and impact
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).
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Diabetes is a chronic condition and people may have had previous foot infections, with previous courses of antibiotics, that will influence their preferences. The committee retained the 2015 recommendation that samples should be taken for microbiological testing before, or as close as possible to, the start of antibiotic treatment. This would allow empirical antibiotic treatment to be changed if needed when results are available. All the risk assessment tools reviewed by the committee were able to predict ulcer occurrence with acceptable accuracy.
- The committee agreed that in their experience, the incidence of diabetic foot infections in children and young people is rare.
- The committee recognised the complexity around interpreting microbiological results, and agreed that the quality and type of specimen should be taken into account when making decisions around whether to change an antibiotic.
- Skin takes some time to return to normal, and full resolution of symptoms after a course of antibiotics is not expected.
- It is also a chance to teach people how to look after their feet, and to emphasise the importance of doing so.
Given this evidence, the committee discussed reducing the frequency of foot risk assessments to once every 2 years. 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 assessing the risk of developing a diabetic foot problem. The committee agreed to retain the 2015 recommendation that antibiotics should not be given to prevent diabetic foot infections. No evidence was identified for antibiotic prophylaxis and the committee agreed that antibiotic prophylaxis is not appropriate because of concerns about antimicrobial resistance. People should be advised to seek medical help if symptoms of a diabetic foot infection develop.
Terms used in this guideline
- The choice of antibiotic would depend on the severity of infection, although the committee acknowledged that the studies they looked at did not always differentiate between severities.
- And they may benefit from regular advice about risk factors for foot problems.
- No evidence was identified for antibiotic prophylaxis and the committee agreed that antibiotic prophylaxis is not appropriate because of concerns about antimicrobial resistance.
- Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
This means using narrow-spectrum antibiotics first where possible, and using gen z alphabet 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.
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 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.
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.
Patient information about the risk of developing a diabetic foot problem
For moderate or severe infection, the committee recommended flucloxacillin at a dose of 1 g four times a day. Based on evidence, their experience and resistance data, the committee agreed that flucloxacillin is an effective empirical antibiotic for mild diabetic foot infections (with dosing taking account of a person’s body weight and renal function). The committee agreed that in their experience, the incidence of diabetic foot infections in children and young people is rare. The mean age of participants in the evidence considered ranged from 54 to 64 years. Based on these factors, the committee included an antibiotic prescribing table for adults, but not for children and young people.
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Reducing the frequency of foot assessments would mean reducing the number of chances to encourage good foot care and direct people to sources of support. Seek specialist advice when prescribing antibiotics for a suspected diabetic foot infection in children and young people under 18 years. This guideline covers preventing and managing foot problems in children, young people and adults with diabetes. It aims to reduce variation in practice, including antibiotic prescribing for diabetic foot infections. The committee agreed that when microbiological results are available, they should be used to guide antibiotic choice. The committee recognised the complexity around interpreting microbiological results, and agreed that the quality and type of specimen should be taken into account when making decisions around whether to change an antibiotic.
If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible. If you have a diabetic foot ulcer, your healthcare professional should check the size and depth of the ulcer and look for signs of infection and other problems. The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available.
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.
