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Benjamin Lipsky , USA ( chair ) É ric Senneville , France ( secretary )

Benjamin Lipsky , USA ( chair ) É ric 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

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Benjamin Lipsky , USA ( chair ) É ric Senneville , France ( secretary )

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  1. Benjamin Lipsky, USA (chair) Éric Senneville, France (secretary) ZulfiqaraliAbbas, Tanzania Javier Aragón-Sánchez, Spain MathewDiggle, UK/Canada John Embil, Canada ShigeoKono, Japan Larry Lavery, USA Matthew Malone, Australia Suzanne van Asten, the Netherlands VilmaUrbančič-Rovan, Slovenia Edgar Peters, the Netherlands (secretary) www.iwgdfguidelines.org

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

  3. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org History of IWGDF Foot InfectionGuidelines • 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. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org What’s New in the 2019 InfectionGuidelines? • Committee members: 2 new (diabetologist; podiatrist), 10 returning; nowrepresentativesfrom 8 countries, 5 continents • Systematic reviews: first review of diagnosis of infection; update of previous review of interventionsforinfection • Infectionseverityclassification: first change; osteomyelitisremovedfrom “moderate” and has separate designation “O” • Format: Changedfromlargelycategorystyletousing “PICOs” • Updates: 4 tables (infectionclassificationscheme; characteristics of seriousinfection; features of osteomyelitis on plain X-rays; empiricantibioticregimens); 1 algorithm (overview of management)

  5. 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 adjunctivetreatments - Diagnosis: 9 (3 specificallyregarding osteomyelitis) - Management: 1 (hospitalization) • Strength: 16 strong; 11 weak • Quality: 17 low; 9 moderate; 1 high

  6. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org KeyRecommendations: Diagnosis • Assessalldiabeticfootulcers (wounds) usingthe IDSA/IWGDF classification • Hospitalizepatientifseriousinfection; outpatienttreament adequate formany moderate & most mild infections • Helpfulclinicaldiagnostic tests: probe-to-bone test; serum inflammatory markers (especially CRP & ESR, ± PCT) • Culture tissue (notswab) specimens of infected (notuninfected) woundsusing standard (ratherthan molecular) methods • Sample boneifneededfordefinitive diagnosis of osteomyelitis or todeterminecausativepathogen(s) & susceptibiltiyresults • Plain X-raysoftensufficientfor imaging; ifadvanced imaging needed MRI usually best, or consider WBC scintigraphy or PET/CT

  7. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org KeyRecommendations: Treatment 1 • Treatinfectionswithantibioticsshowntobeeffective in clinical trials • Select agent(s) based on: likelypathogen(s) & susceptibilites; clinicalseverity of infection; publishedevidence of efficacy; risk of adverse events or drug interactions; boneinvolvement; availability; cost • Treatparenterallyfor severe infectionsinitially; switch tooralagents (ifappropriateoneavailable) whenpatientstable. • Treatwithoralagentsfor mild and most moderate infections • Using availabletopicalantimicrobials is notsupportedbypublished data • Therapyduration: 1-2 weeks usually adequate for soft tissue; ≤6 weeks forboneinfection (5-7 daysifall osteomyelitis resected)

  8. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org KeyRecommendations: Treatment 2 • In temperateclimatesforpatientswith no recent antibiotictherapy, target only aerobic GPCs (S. aureus, β-streptococcus) • In tropical/subtropicalclimates, or if recent antibiotictherapy, addcoveragefor aerobic GNRs (possiblyincludingPseudomonas), andpossiblyfor obligate anaerobics (especiallyiflimbischemia) • Do nottreatclinicallyuninfectedwoundswithantimicrobials • A surgeonshouldurgentlyevaluateall severe, andmany moderate infections, especiallyif ? gangrene, abscess, compartmentsyndrome • Many cases of forefoot osteomyelitis canbetreatedmedically, but surgicalresection (preferablyconservative) maybe best forothers

  9. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org KeyRecommendations: Treatment 3 • Duringsurgerytoresectinfectedbone, it is likelyusefultoobtain a “marginal” sample toensureresidualboneuninfected; ifnot, treat • Adjunctivetherapies have not (yet) been showntobeeffectivefortreatingtheinfectiousaspects of diabeticfootwounds, including: hyperbaricoxygen; G-CSF; topicalantiseptics; negativepressurewoundtherapy; bacteriophages • For complicated cases seek input frominfectiousdiseases/clinicalmicrobiologycliniciansandmultidisciplinary teams • Most appropriatelytreatedinfectionscanbesucessfullytreated, but relapses andreinfections 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 obtainingmarginalboneafterresectionhelpfulforselecting best treatment • Is “woundbioburden” a definable or useful concept • Whenmight molecular (genotypic) microbiologytechniquesbeuseful • How to monitor treatment & limit antibioticduration (soft tissue & boneinfxn) • How toadapt approaches to DFI management in low-incomecountries • Whenmighttopical/localantimicrobialtherapybeuseful • How todeterminethepresenceand treatment of biofilminfection

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

  12. 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

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