Guidance

Recommendations

Recommendations

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.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Care within 24 hours of a person with diabetic foot problems being admitted to hospital, or the detection of diabetic foot problems (if the person is already in hospital)

1.1.1

Each hospital should have a care pathway for people with diabetic foot problems who need inpatient care. [2011]

1.1.2

A named consultant should be accountable for the overall care of the person, and for ensuring that healthcare professionals provide timely care. [2011]

1.1.3

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. [2011]

1.1.4

The named consultant and the healthcare professionals from the existing team should remain accountable for the care of the person unless their care is transferred to the multidisciplinary foot care service. [2011]

1.2 Care across all settings

1.2.1

Commissioners and service providers should ensure that the following are in place:

  • A foot protection service for preventing diabetic foot problems, and for treating and managing diabetic foot problems in the community.

  • A multidisciplinary foot care service for managing diabetic foot problems in hospital and in the community that cannot be managed by the foot protection service. This may also be known as an interdisciplinary foot care service.

  • Robust protocols and clear local pathways for the continued and integrated care of people across all settings including emergency care and general practice. The protocols should set out the relationship between the foot protection service and the multidisciplinary foot care service.

  • Regular reviews of treatment and patient outcomes, in line with the National Diabetes Foot Care Audit. [2015]

1.2.2

The foot protection service should be led by a podiatrist with specialist training in diabetic foot problems, and should have access to healthcare professionals with skills in the following areas:

  • Diabetology.

  • Biomechanics and orthoses.

  • Wound care. [2015]

1.2.3

The multidisciplinary foot care service should be led by a named healthcare professional, and consist of specialists with skills in the following areas:

  • Diabetology.

  • Podiatry.

  • Diabetes specialist nursing.

  • Vascular surgery.

  • Microbiology.

  • Orthopaedic surgery.

  • Biomechanics and orthoses.

  • Interventional radiology.

  • Casting.

  • Wound care. [2015]

1.2.4

The multidisciplinary foot care service should have access to rehabilitation services, plastic surgery, psychological services and nutritional services. [2015]

1.2.5

Healthcare professionals may need to discuss, agree and make special arrangements for disabled people and people who are housebound or living in care settings, to ensure equality of access to foot care assessments and treatments for people with diabetes. [2015]

1.2.6

Take into account any disabilities, including visual impairment, when planning and delivering care for people with diabetes. [2015]

1.3 Assessing the risk of developing a diabetic foot problem

Frequency of assessments

1.3.1

For children with diabetes who are under 12 years, give them, and their family members or carers (as appropriate), basic foot care advice. [2015]

1.3.2

For young people with diabetes who are 12 to 17 years, the paediatric care team or the transitional care team should assess the young person's feet as part of their annual assessment, and provide information about foot care. If a diabetic foot problem is found or suspected, the paediatric care team or the transitional care team should refer the young person to an appropriate specialist. [2015]

Assessing the risk of developing a diabetic foot problem

1.3.4

When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings, and examine both feet for evidence of the following risk factors:

  • neuropathy (use a 10 g monofilament as part of a foot sensory examination)

  • limb ischaemia (see the NICE guideline on peripheral arterial disease)

  • ulceration

  • callus

  • infection and/or inflammation

  • deformity

  • gangrene

  • Charcot arthropathy. [2023]

1.3.6

Assess the person's current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification:

  • Low risk:

    • no risk factors present except callus alone.

  • Moderate risk:

    • deformity or

    • neuropathy or

    • peripheral arterial disease.

  • High risk:

    • previous ulceration or

    • previous amputation or

    • on renal replacement therapy or

    • neuropathy and peripheral arterial disease together or

    • neuropathy in combination with callus and/or deformity or

    • peripheral arterial disease in combination with callus and/or deformity.

  • Active diabetic foot problem:

    • ulceration or

    • infection or

    • chronic limb-threatening ischaemia or

    • gangrene or

    • suspicion of an acute Charcot arthropathy, or an unexplained hot, swollen foot with a change in colour, with or without pain. [2023]

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.

Full details of the evidence and the committee's discussion are in evidence review B: risk assessment models and tools for predicting the development of diabetic foot problems and foot review frequency.

Managing the risk of developing a diabetic foot problem

1.3.8

Refer people who are at moderate or high risk of developing a diabetic foot problem to the foot protection service. [2015]

1.3.9

The foot protection service should assess newly referred people as follows:

  • Within 2 to 4 weeks for people who are at high risk of developing a diabetic foot problem.

  • Within 6 to 8 weeks for people who are at moderate risk of developing a diabetic foot problem. [2015]

1.3.10

For people at moderate or high risk of developing a diabetic foot problem, the foot protection service should:

  • Assess the feet.

  • Give advice about, and provide, skin and nail care of the feet.

  • Assess the biomechanical status of the feet, including the need to provide specialist footwear and orthoses.

  • Assess the vascular status of the lower limbs.

  • Liaise with other healthcare professionals, for example, the person's GP, about the person's diabetes management and risk of cardiovascular disease. [2015]

1.3.11

Depending on the person's risk of developing a diabetic foot problem, carry out reassessments at the following intervals:

  • Annually for people who are at low risk, as part of their annual diabetes review.

  • Frequently (for example, every 3 to 6 months) for people who are at moderate risk.

  • More frequently (for example, every 1 to 2 months) for people who are at high risk, if there is no immediate concern.

  • Very frequently (for example, every 1 to 2 weeks) for people who are at high risk, if there is immediate concern.

  • Consider more frequent reassessments for people who are at moderate or high risk, and for people who are unable to check their own feet. [2023]

1.3.12

People in hospital who are at moderate or high risk of developing a diabetic foot problem should be given a pressure redistribution device to offload heel pressure. On discharge they should be referred or notified to the foot protection service. [2015]

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.

Full details of the evidence and the committee's discussion are in evidence review B: risk assessment models and tools for predicting the development of diabetic foot problems and foot review frequency.

Patient information about the risk of developing a diabetic foot problem

1.3.13

Provide information and clear explanations to people with diabetes and/or their family members or carers (as appropriate) when diabetes is diagnosed, during assessments, and if problems arise. Information should be oral and written, and include the following:

  • Basic foot care advice and the importance of foot care.

  • Foot emergencies and who to contact.

  • Footwear advice.

  • The person's current individual risk of developing a foot problem.

  • Information about diabetes and the importance of blood glucose control (also see recommendation 1.3.14). [2015]

1.3.14

For guidance on education programmes and information about diabetes, see the education and information section in the NICE guideline on type 1 diabetes in adults, the education section in the NICE guideline on type 2 diabetes in adults, and the sections on education and information for children and young people with type 1 diabetes and education and information for children and young people with type 2 diabetes in the NICE guideline on diabetes (type 1 and type 2) in children and young people. [2015]

1.4 Diabetic foot problems

Referral

1.4.1

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 the recommendation on services and protocols commissioners and service providers should ensure are in place), 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.

  • Ulceration with limb ischaemia (see the NICE guideline on 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). [2015]

Patient information about diabetic foot problems

1.4.3

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:

1.5 Diabetic foot ulcer

Investigation

1.5.1

If a person has a diabetic foot ulcer, assess and document the size, depth and position of the ulcer. [2015]

1.5.2

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. [2015]

1.5.3

Do not use the Wagner classification system to assess the severity of a diabetic foot ulcer. [2015]

Treatment

1.5.4

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. [2015]

1.5.5

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. [2015]

1.5.6

In line with the NICE guideline on pressure ulcers, use pressure-redistributing devices and strategies to minimise the risk of pressure ulcers developing. [2015]

1.5.7

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. [2015]

1.5.8

When treating diabetic foot ulcers, debridement in the community should only be done by healthcare professionals with the relevant training and skills, continuing the care described in the person's treatment plan. [2015]

1.5.9

Consider negative pressure wound therapy after surgical debridement for diabetic foot ulcers, on the advice of the multidisciplinary foot care service. [2015]

1.5.10

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. [2015]

1.5.11

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. [2015]

1.5.12

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. [2015]

1.5.13

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. [2015]

1.5.14

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. [2015]

1.6 Diabetic foot infection

Investigation

1.6.1

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. [2015]

1.6.2

Consider an X‑ray of the person's affected foot (or feet) to determine the extent of the diabetic foot problem. [2015]

1.6.3

Think about osteomyelitis if the person with diabetes has a local infection, a deep foot wound or a chronic foot wound. [2015]

1.6.4

Be aware that osteomyelitis may be present in a person with diabetes despite normal inflammatory markers, X‑rays or probe-to-bone testing. [2015]

1.6.5

If osteomyelitis is suspected in a person with diabetes but is not confirmed by initial X‑ray, consider an MRI to confirm the diagnosis. [2015]

Treatment

1.6.6

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. [2019]

1.6.7

When choosing an antibiotic for people with a suspected diabetic foot infection (see recommendations 1.6.8 and 1.6.9), 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. [2019]

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.

Full details of the evidence and the committee's discussion are in evidence review A: diabetic foot infection: antimicrobial prescribing.

Choice of antibiotic

1.6.8

When prescribing antibiotics for a suspected diabetic foot infection in adults aged 18 years and over, follow table 1 for a mild infection or table 2 for a moderate or severe infection. [2019]

1.6.9

Seek specialist advice when prescribing antibiotics for a suspected diabetic foot infection in children and young people under 18 years. [2019]

1.6.10

Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics. [2019]

1.6.11

If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible. [2019]

1.6.12

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. [2019]

Table 1 Antibiotics for mild diabetic foot infection in adults aged 18 years and over
First-choice oral antibiotic
Antibiotic Dosage and course length

See BNF for appropriate use and dosing in specific populations, for example, people with hepatic or renal impairment, or who are pregnant or breastfeeding

Oral doses are for immediate-release medicines

Flucloxacillin

500 mg to 1 g four times a day for 7 days

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

In August 2015, the upper dose of 1 g four times a day was off label. See NICE's information on prescribing medicines
Alternative oral antibiotics for penicillin allergy or if flucloxacillin unsuitable (guided by microbiological results when available)
Antibiotic Dosage and course length

See BNF for appropriate use and dosing in specific populations, for example, people with hepatic or renal impairment, or who are pregnant or breastfeeding

Oral doses are for immediate-release medicines

Clarithromycin

500 mg twice a day for 7 days

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

Erythromycin (in pregnancy)

500 mg four times a day for 7 days

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

Doxycycline

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

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
Table 2 Antibiotics for moderate or severe diabetic foot infection in adults aged 18 years and over
First-choice antibiotics (guided by microbiological results when available); in severe infection, give intravenously for at least 48 hours (until stabilised)
Antibiotic Dosage

See BNF for appropriate use and dosing in specific populations, for example, people with hepatic or renal impairment, or who are pregnant or breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics

Oral doses are for immediate-release medicines

Flucloxacillin with or without

1 g four times a day orally or 1 to 2 g four times a day IV

In August 2015, the dose of 1 g four times a day was off label. See NICE's information on prescribing medicines

Gentamicin and/or

Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted according to serum gentamicin concentration

See BNF for information on therapeutic drug monitoring and monitoring of patient parameters

Metronidazole

400 mg three times a day orally or 500 mg three times a day IV

Co-amoxiclav with or without

500/125 mg three times a day orally or 1.2 g three times a day IV

Gentamicin

Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted according to serum gentamicin concentration

See BNF for information on therapeutic drug monitoring and monitoring of patient parameters

Co-trimoxazole (in penicillin allergy) with or without

960 mg twice a day orally or 960 mg twice a day IV (can be increased to 1.44 g twice a day)

See BNF for information on monitoring of patient parameters

In August 2015, this was not licensed for diabetic foot infection, so was off label. See NICE's information on prescribing medicines

Gentamicin and/or

Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted according to serum gentamicin concentration

See BNF for information on therapeutic drug monitoring and monitoring of patient parameters

Metronidazole

400 mg three times a day orally or 500 mg three times a day IV

Ceftriaxone with

2 g once a day IV

Metronidazole

400 mg three times a day orally or 500 mg three times a day IV

Course length is based on clinical assessment: minimum of 7 days and up to 6 weeks for osteomyelitis (use oral antibiotics for prolonged treatment).

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

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

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

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.

Additional antibiotic choices if Pseudomonas aeruginosa suspected or confirmed (guided by microbiological results when available)
Antibiotic Dosage

See BNF for appropriate use and dosing in specific populations, for example, people with hepatic or renal impairment, or who are pregnant or breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics

Oral doses are for immediate-release medicines

Piperacillin with tazobactam

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

Clindamycin with

150 to 300 mg four times a day orally (can be increased to 450 mg four times a day) or 600 mg to 2.7 g daily IV in two to four divided doses, increased if necessary in life-threatening infection to 4.8 g daily (maximum per dose 1.2 g)

Ciprofloxacin and/or

500 mg twice a day orally or 400 mg two or three times a day IV

See the MHRA January 2024 advice on restrictions and precautions for using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects. Fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate

Gentamicin

Initially 5 to 7 mg/kg once a day IV, subsequent doses adjusted according to serum gentamicin concentration

See BNF for information on therapeutic drug monitoring and monitoring of patient parameters

Course length is based on clinical assessment: minimum of 7 days and up to 6 weeks for osteomyelitis (use oral antibiotics for prolonged treatment).

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

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

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

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

Antibiotics to be added if MRSA infection suspected or confirmed (combination therapy with an antibiotic listed above)
Antibiotic Dosage

See BNF for appropriate use and dosing in specific populations, for example, people with hepatic or renal impairment, or who are pregnant or breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics

Oral doses are for immediate-release medicines

Vancomycin

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

See BNF for information on therapeutic drug monitoring and monitoring of patient parameters

Teicoplanin

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

See BNF for information on therapeutic drug monitoring and monitoring of patient parameters

Linezolid (if vancomycin or teicoplanin cannot be used; specialist use only)

600 mg twice a day orally

600 mg twice a day IV

See BNF for information on monitoring of patient parameters

Course length is based on clinical assessment: minimum of 7 days and up to 6 weeks for osteomyelitis (use oral antibiotics for prolonged treatment).

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

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

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.

Full details of the evidence and the committee's discussion are in evidence review A: diabetic foot infection: antimicrobial prescribing.

Advice

1.6.13

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. [2019]

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.

Full details of the evidence and the committee's discussion are in evidence review A: diabetic foot infection: antimicrobial prescribing.

Reassessment

1.6.14

When microbiological results are available:

  • review the choice of antibiotic and

  • change the antibiotic according to results, using a narrow-spectrum antibiotic, if appropriate. [2019]

1.6.15

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. [2019]

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 reassessment.

Full details of the evidence and the committee's discussion are in evidence review A: diabetic foot infection: antimicrobial prescribing.

Prevention

1.6.16

Do not offer antibiotics to prevent diabetic foot infections. Give advice about seeking medical help if symptoms of a diabetic foot infection develop. [2019]

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 prevention.

Full details of the evidence and the committee's discussion are in evidence review A: diabetic foot infection: antimicrobial prescribing.

1.7 Charcot arthropathy

Investigation

1.7.1

Be aware that if a person with diabetes fractures their foot or ankle, it may progress to Charcot arthropathy. [2015]

1.7.2

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. [2015]

1.7.3

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. [2015]

1.7.4

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. [2015]

Treatment

1.7.5

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. [2015]

1.7.6

Do not offer bisphosphonates to treat acute Charcot arthropathy, unless as part of a clinical trial. [2015]

1.7.7

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. [2015]

1.7.8

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. [2015]

Terms used in this guideline

Diabetic foot infection

Diabetic foot infection is defined by the presence of at least 2 of the following:

  • local swelling or induration

  • erythema

  • local tenderness or pain

  • local warmth

  • purulent discharge.

Mild diabetic foot infection

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 diabetic foot infection

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.

Severe diabetic foot infection

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

Diabetic foot problem

'Diabetic foot problem' refers to any problem affecting the feet in people with diabetes that is caused by loss of sensation (peripheral sensory neuropathy) and/or circulation problems (peripheral arterial disease).

Diabetic foot problems include:

  • diabetic foot ulcers

  • soft tissue infection

  • destruction of the deep tissues such as heel pressure sores

  • osteomyelitis (bone infection)

  • Charcot arthropathy.

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.