Éric Senneville, France (secretary) Benjamin Lipsky, USA (chair) Éric Senneville, France (secretary) Zulfiqarali Abbas, Tanzania Javier Aragón-Sánchez, Spain Mathew Diggle, UK/Canada John Embil, Canada Shigeo Kono, Japan Larry Lavery, USA Matthew Malone, Australia Suzanne van Asten, the Netherlands Vilma Urbančič-Rovan, Slovenia Edgar Peters, the Netherlands (secretary) www.iwgdfguidelines.org

IWGDF Infection Working Group 2019 Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Aragón- Sánchez Lavery Abbas Embil Lipsky Diggle Peters Malone Van Asten Kono Urbančič- Rovan Senneville

History of IWGDF Foot Infection Guidelines Slides courtesy IWGDF; available at: www.iwgdfguidelines.org History of IWGDF Foot Infection Guidelines Diagnosing and treating diabetic foot infections. Lipsky BA, Berendt AR, Embil J, De Lalla F. Diabetes Metab Res Rev. 2004;20 Suppl 1:S56-64 Specific guidelines for treatment of diabetic foot osteomyelitis. Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ, Jeffcoate WJ, Lipsky BA, Senneville E, Teh J, Valk GD. Diabetes Metab Res Rev. 2008;24 Suppl 1:S190-1 Expert opinion on the management of infections in the diabetic foot. Lipsky BA, Peters EJ, Senneville E, Berendt AR, Embil JM, Lavery LA, Urbančič-Rovan V, Jeffcoate WJ; IWGDF. Diabetes Metab Res Rev. 2012;28 Suppl 1:163-78 IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J, Kono S, Lavery L, Senneville É, Urbančič-Rovan V, Van Asten S, Peters EJ; International Working Group on the Diabetic Foot. Diabetes Metab Res Rev. 2016;32 Suppl 1:45-74

What’s New in the 2019 Infection Guidelines? Slides courtesy IWGDF; available at: www.iwgdfguidelines.org What’s New in the 2019 Infection Guidelines? Committee members: 2 new (diabetologist; podiatrist), 10 returning; now representatives from 8 countries, 5 continents Systematic reviews: first review of diagnosis of infection; update of previous review of interventions for infection Infection severity classification: first change; osteomyelitis removed from “moderate” and has separate designation “O” Format: Changed from largely category style to using “PICOs” Updates: 4 tables (infection classification scheme; characteristics of serious infection ; features of osteomyelitis on plain X-rays; empiric antibiotic regimens); 1 algorithm (overview of management)

Recommendations: total of 27 Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Recommendations: total of 27 Topic - Treatment: 17 11 on antimicrobials 2 on surgery 3 on osteomyelitis 2 on adjunctive treatments - Diagnosis: 9 (3 specifically regarding osteomyelitis) - Management: 1 (hospitalization) Strength: 16 strong; 11 weak Quality: 17 low; 9 moderate; 1 high

Key Recommendations: Diagnosis Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Key Recommendations: Diagnosis Assess all diabetic foot ulcers (wounds) using the IDSA/IWGDF classification Hospitalize patient if serious infection; outpatient treament adequate for many moderate & most mild infections Helpful clinical diagnostic tests: probe-to-bone test; serum inflammatory markers (especially CRP & ESR, ± PCT) Culture tissue (not swab) specimens of infected (not uninfected) wounds using standard (rather than molecular) methods Sample bone if needed for definitive diagnosis of osteomyelitis or to determine causative pathogen(s) & susceptibiltiy results Plain X-rays often sufficient for imaging; if advanced imaging needed MRI usually best, or consider WBC scintigraphy or PET/CT

Key Recommendations: Treatment 1 Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Key Recommendations: Treatment 1 Treat infections with antibiotics shown to be effective in clinical trials Select agent(s) based on: likely pathogen(s) & susceptibilites; clinical severity of infection; published evidence of efficacy; risk of adverse events or drug interactions; bone involvement; availability; cost Treat parenterally for severe infections initially; switch to oral agents (if appropriate one available) when patient stable. Treat with oral agents for mild and most moderate infections Using available topical antimicrobials is not supported by published data Therapy duration: 1-2 weeks usually adequate for soft tissue; ≤6 weeks for bone infection (5-7 days if all osteomyelitis resected)

Key Recommendations: Treatment 2 Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Key Recommendations: Treatment 2 In temperate climates for patients with no recent antibiotic therapy, target only aerobic GPCs (S. aureus, β-streptococcus) In tropical/subtropical climates, or if recent antibiotic therapy, add coverage for aerobic GNRs (possibly including Pseudomonas), and possibly for obligate anaerobics (especially if limb ischemia) Do not treat clinically uninfected wounds with antimicrobials A surgeon should urgently evaluate all severe, and many moderate infections, especially if ? gangrene, abscess, compartment syndrome Many cases of forefoot osteomyelitis can be treated medically, but surgical resection (preferably conservative) may be best for others

Key Recommendations: Treatment 3 Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Key Recommendations: Treatment 3 During surgery to resect infected bone, it is likely useful to obtain a “marginal” sample to ensure residual bone uninfected; if not, treat Adjunctive therapies have not (yet) been shown to be effective for treating the infectious aspects of diabetic foot wounds, including: hyperbaric oxygen; G-CSF; topical antiseptics; negative pressure wound therapy; bacteriophages For complicated cases seek input from infectious diseases/clinical microbiology clinicians and multidisciplinary teams Most appropriately treated infections can be sucessfully treated, but relapses and reinfections are common

Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Key Controversies What is the best approach to imaging bone & soft tissue infections Is obtaining marginal bone after resection helpful for selecting best treatment Is “wound bioburden” a definable or useful concept When might molecular (genotypic) microbiology techniques be useful How to monitor treatment & limit antibiotic duration (soft tissue & bone infxn) How to adapt approaches to DFI management in low-income countries When might topical/local antimicrobial therapy be useful How to determine the presence and treatment of biofilm infection

Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Thank you

IWGDF Guideline on the Diagnosis and Treatment Slides courtesy IWGDF; available at: www.iwgdfguidelines.org IWGDF Guideline on the Diagnosis and Treatment of Foot Infection in People with Diabetes Benjamin A. Lipsky, USA (chair) Shigeo Kono, Japan Éric Senneville, France (secretary) Lawrence A. Lavery, USA Zulfiqarali G. Abbas, Tanzania Matthew Malone, Australia Javier Aragón-Sánchez, Spain Suzanne A. van Asten, Netherlands Mathew Diggle, UK/Canada Vilma Urbančič-Rovan, Slovenia John M. Embil, Canada Edgar J.G. Peters, Netherlands (secretary) www.iwgdfguidelines.org