Original Title: Infection du pied diabétique chez l’adulte : usage optimal de l’antibiothérapie et mesures de prévention des récidives

Authors' objectives: Diabetes is associated with a number of complications, including peripheral neuropathy (loss of sensitivity to pain) which, in 10–25% of cases, can lead to the development of diabetic foot ulcers. When combined with inadequate arterial blood flow, this ulcer presents a higher risk of infection and complications that, in almost 50% of cases, lead to amputation within a same year. Early recognition and appropriate management of diabetic foot ulcer infections can usually prevent or delay this escalation. According to recommended interventions documented in a series of wound care clinical tools published by the Institut national d'excellence en santé et en services sociaux (INESSS) in 2024, diabetic foot ulcer infection can be treated according to the following five principles: 1) pressure relief through offloading modalities, 2) revascularization (if vascular supply to the wound is inadequate), 3) wound cleansing and debridement, 4) use of an antiseptic agent and 5) metabolic control. However, the use of an oral or intravenous antibiotic may be necessary to support the five principles if the infection spreads to the soft tissues or becomes systemic. Given the evolution of knowledge and the needs expressed by clinical communities, the Institut national d'excellence en santé et en services sociaux (INESSS) has deemed it necessary to carry out a complete overhaul of its guide, in line with the most recent scientific data and trends in best practice on the subject, particularly with regard to antibiotic governance.

Authors' results and conclusions: RESULTS (#1 CONSOLIDATE THE CLINICAL REPRESENTATION OF A DIABETIC FOOT INFECTION THAT SPREADS TO SOFT TISSUES AND/OR AN OSTEOARTICULAR INFECTION): The information gathered during the initial stages of assessment is generally put into perspective according to the risk of complication of the infection, an aspect that was less developed in the previous optimal use guide. (#2 REDUCING THE INAPPROPRIATE USE OF WOUND CULTURE): The decision to use wound culture is dictated by the relevance of identifying the causative agents in order to select the most appropriate antibiotic. Wound culture requires good-quality exudate obtained using the Levine technique. However, mild infections of varying extent and less severe moderate infections do not usually produce such exudate. (#3 DESIGNING THE OPTIMAL TREATMENT PLAN): For a mild infection, the administration of a cephalosporin—cefadroxil or cephalexin—for 5 days is preferred, unless a polymicrobial infection is suspected, which requires amoxicillin/clavulanate for broader antimicrobial coverage. The duration can be extended to 7 to 10 days if the more extensive mild infection tends towards a moderate infection. For moderate infections, amoxicillin/clavulanate is the first choice of antibiotics. The per os administration of antibiotics is generally favoured in the treatment of diabetic foot infection. However, intravenous antibiotic alternatives such as intravenous amoxicillin/clavulanate and cephalosporins—ceftriaxone or cefazolin—may prove useful, depending on the severity of the infection, the presence of doubts about infection progression and the impossibility of using the oral route, and all this while weighing up the advantages and disadvantages of their use. (#4 RETHINKING THE TREATMENT PLAN IN THE EVENT OF FAILURE): The new version of the clinical tool specifies that, in the event of failure of first-line antibiotic treatment, it is essential to examine the treatment plan as a whole. In this context, good clinical practice dictates the optimization of strict offloading, wound bed preparation and treatment compliance, including healthy lifestyles. Re-evaluation of the possible causes of the onset of signs and symptoms, with particular attention to neuropathy, deep infection, superinfection, osteomyelitis and ischemia, as well as differential diagnosis, are also essential components of management. (#5 CONSULTING ACCORDING TO RISK OF INFECTION COMPLICATIONS): Management of infection at the emergency department is required in the presence of systemic or severe infection, rapidly progressive necrotizing soft-tissue infection, including necrotizing fasciitis, deep abscesses or compartment syndrome. As the diabetic foot is often associated with loss of sensation in the foot, uncontrollable pain is an alarming situation that may indicate a condition more complex than a diabetic foot infection. (#6 REDUCING RECURRENCE BY CONTROLLING RISK FACTORS): The most effective way to prevent recurrence is to control or eliminate, where possible, the risk factors for developing an infection. These include, but are not limited to, uncontrolled diabetes with prolonged hyperglycemia, inadequate vascular supply, neuropathy, renal failure, obesity, traumatic wound or amputation history, lack of strict offloading, lack of local care, recurrent ulcer or ulcer more than 30 days old. Moreover, the active participation of the patient in the management of his or her wound is a key factor in preventing recurrence.

Authors' recommendations: To optimize diabetic foot infection practice, it is suggested that: • the healthcare institutions, family medicine groups and medical/nursing clinics: − include a website link for the optimal use guide in their protocols and tools, or host the most up-to-date version of the INESSS guide in their healthcare and pharmaceutical software; – update protocols, standardized individual prescriptions and clinical tools developed in their environment concerning this infection, as required; • the educational institutions: – update the basic training offered to future clinicians who will be called upon to identify and diagnose this infection; • associations, federations and professional orders: – update training already available to enhance knowledge of optimal therapeutic conduct according to severity of infection and risk of complications; • ministère de la Santé and Santé Québec : – promote the development of clinics for the infected diabetic foot, as it is currently done for infectious cellulitis; – facilitate access to multidisciplinary wound-care teams in all facilities across Quebec, to support first-line and home-care teams;

Authors' methods: For this work, the evaluation questions were formulated to cover the population, clinical and organizational dimensions, while also considering the economic and socio-cultural dimensions, as well as the ethical issues as presented in the INESSS Énoncé de principes et fondements éthiques (Statement of Principles and Ethical Foundations). In collaboration with a scientific information consultant (librarian), a systematic search of the scientific literature published up to March 2024 was carried out in the MEDLINE, Embase and Cochrane Central Register of Controlled Trials—EBM Reviews and CINAHL Complete databases. A manual search of the grey literature was also carried out, consulting, among others, the websites of clinical societies specializing in the subject area of the work, as well as regulatory, public health or health technology assessment agencies, government bodies, professional associations and healthcare institutions. A targeted literature watch was carried out until December 2024. The selection, extraction of information and assessment of the methodological quality of the selected documents were carried out independently by two scientific professionals. Official monographs for drugs approved by Health Canada, as well as tertiary references in pharmacotherapy and medical reference works by Quebec experts in the field, were consulted, as were the drug reimbursement lists and criteria of Quebec's general prescription drug insurance plan. The data and contextual elements gathered were analyzed and synthesized by one professional, then validated by another. This analysis was carried out with a view to contextualizing practice in Quebec, based in particular on elements of the legislative, regulatory and organizational context specific to Quebec, and on the perspective of the various stakeholders consulted. Stakeholders' perspectives were gathered through an advisory committee made up of healthcare professionals from different specialties and areas of expertise. The identification of key clinical benchmarks and the formulation of recommendations were carried out in collaboration with the members of the advisory committee, based in particular on an assessment of all the documented evidence. Finally, the overall quality of the work, its acceptability and applicability were assessed by external readers specializing in the field of interest, as well as future users who had not participated in the work.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/infection-du-pied-diabetique-chez-ladulte-usage-optimal-de-lantibiotherapie-et-mesures-de-prevention-des-recidives.html

Year Published: 2025

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/infection-du-pied-diabetique-chez-ladulte-usage-optimal-de-lantibiotherapie-et-mesures-de-prevention-des-recidives.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)