1. 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)

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

3. History of IWGDF Foot Infection Guidelines
Slides courtesy IWGDF; available at:
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

4. What’s New in the 2019 Infection Guidelines?
Slides courtesy IWGDF; available at:
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)

5. Recommendations: total of 27
Slides courtesy IWGDF; available at:
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

6. Key Recommendations: Diagnosis
Slides courtesy IWGDF; available at:
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

7. Key Recommendations: Treatment 1
Slides courtesy IWGDF; available at:
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)

8. Key Recommendations: Treatment 2
Slides courtesy IWGDF; available at:
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

9. Key Recommendations: Treatment 3
Slides courtesy IWGDF; available at:
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

10. 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

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

12. IWGDF Guideline on the Diagnosis and Treatment
Slides courtesy IWGDF; available at:
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)