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      Utilisation of the 2019 IWGDF diabetic foot infection guidelines to benchmark practice and improve the delivery of care in persons with diabetic foot infections

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          Abstract

          Aims

          To utilise the 2019 International Working Group on the Diabetic Foot (IWGDF) - diabetic foot infection (DFI) guidelines as an audit tool for clinical practice in patients with diabetes attending a High-Risk Foot Service.

          Methods

          Data from 93 consecutive patients were collected over a 19-month period in patients attending a High-Risk Foot Service. The diagnosis and management of each patient in the sample were compared against the 2019 IWGDF DFI guidelines, grouped into four categories: Diagnosis, Microbiology, Treatment of soft tissue infection, and Surgical treatment and osteomyelitis. Deficits in performance were recorded using the recommendations as a benchmark standard.

          Results

          There were 109 DFI events. Nineteen (63%) of the recommendations were met, 7 (24%) were partially met, and four (13%) recommendations were not met. Fourteen of the sample had no documented requests for full blood counts. Tissue was obtained for culture in 32 (29%) of the sample. No percutaneous bone biopsies were performed. Only 13 (28%) patients had intraoperative bone specimens sent for culture and sensitivities, with no bone specimens sent for histopathology. Modification of antibiotic therapy following available culture results was low, occurring in 12 out of 63 possible occasions (19%). The duration of antibiotic regimens in PEDIS 2 infections and osteomyelitis was greater than that recommended.

          Conclusions

          Utilising the IWGDF DFI guidelines to benchmark clinical practice is a useful tool to identify gaps in clinical performance or service delivery and may help to improve patient care.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s13047-021-00448-w.

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          Most cited references17

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          Oral versus Intravenous Antibiotics for Bone and Joint Infection

          Ho-Kwong Li, Ines Rombach, Rhea Zambellas … (2019)
          The management of complex orthopedic infections usually includes a prolonged course of intravenous antibiotic agents. We investigated whether oral antibiotic therapy is noninferior to intravenous antibiotic therapy for this indication.
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            Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update).

            Benjamin A. Lipsky, Éric Senneville, Zulfiqarali G. Abbas … (2020)
            The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.
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              Risk factors for foot infections in individuals with diabetes.

              S Brismar-Wendel, Lawrence A. Lavery, Kendall M. Mohler … (2006)
              To prospectively determine risk factors for foot infection in a cohort of people with diabetes. We evaluated then followed 1,666 consecutive diabetic patients enrolled in a managed care-based outpatient clinic in a 2-year longitudinal outcomes study. At enrollment, patients underwent a standardized general medical examination and detailed foot assessment and were educated about proper foot care. They were then rescreened at scheduled intervals and also seen promptly if they developed any foot problem. During the evaluation period, 151 (9.1%) patients developed 199 foot infections, all but one involving a wound or penetrating injury. Most patients had infections involving only the soft tissue, but 19.9% had bone culture-proven osteomyelitis. For those who developed a foot infection, compared with those who did not, the risk of hospitalization was 55.7 times greater (95% CI 30.3-102.2; P 30 days (4.7), recurrent wounds (2.4), wounds with a traumatic etiology (2.4), and presence of peripheral vascular disease (1.9). Foot infections occur relatively frequently in individuals with diabetes, almost always follow trauma, and dramatically increase the risk of hospitalization and amputation. Efforts to prevent infections should be targeted at people with traumatic foot wounds, especially those that are chronic, deep, recurrent, or associated with peripheral vascular disease.
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                Author and article information

                Contributors
                Matthew Malone:
                ORCID: http://orcid.org/0000-0002-2946-8841
                Matthew.Malone@westernsydney.edu.au
                Adriaan Erasmus: Adriaan.Erasmus@health.nsw.gov.au
                Saskia Schwarzer: Saskia.Schwarzer@health.nsw.gov.au
                Namson S. Lau: namson.lau@sydney.edu.au
                Mehtab Ahmad: tabbyahmad@doctors.org.uk
                Hugh G. Dickson: Hugh.Dickson@health.nsw.gov.au
                Journal
                Journal ID (nlm-ta): J Foot Ankle Res
                Journal ID (iso-abbrev): J Foot Ankle Res
                Title: Journal of Foot and Ankle Research
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1757-1146
                Publication date (Electronic): 28 January 2021
                Publication date PMC-release: 28 January 2021
                Publication date Collection: 2021
                Volume: 14
                Electronic Location Identifier: 10
                Affiliations
                [1 ]GRID grid.415994.4, ISNI 0000 0004 0527 9653, High Risk Foot Service, Liverpool Hospital, , South Western Sydney LHD, ; Liverpool, Sydney, NSW 2170 Australia
                [2 ]South West Sydney Limb Preservation and Wound Research Academic Unit, South Western Sydney LHD, Liverpool, Sydney, NSW 2170 Australia
                [3 ]GRID grid.429098.e, Ingham Institute of Applied Medical Research, ; 1 Campbell Street, Liverpool, NSW 2170 Australia
                [4 ]GRID grid.1005.4, ISNI 0000 0004 4902 0432, South West Clinical School, Faculty of Medicine, , University of New South Wales, ; Sydney, Australia
                [5 ]GRID grid.415994.4, ISNI 0000 0004 0527 9653, Department of Vascular Surgery, Liverpool Hospital, , South Western Sydney LHD, ; Liverpool, Sydney, Australia
                Author information
                http://orcid.org/0000-0002-2946-8841
                Article
                Publisher ID: 448
                DOI: 10.1186/s13047-021-00448-w
                PMC ID: 7842064
                PubMed ID: 33509233
                SO-VID: 31e92f85-b7d4-470e-b2fb-f85862073d4f
                Copyright © © The Author(s) 2021
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 2 December 2020
                Date accepted : 7 January 2021
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2021

                ScienceOpen disciplines: Orthopedics
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                ScienceOpen disciplines: Orthopedics

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