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AIMS: Diabetes-related foot disease is a major source of patient burden and societal costs. Investing in evidence-based international guidelines on diabetes-related foot disease is important to reduce this burden and costs, provided the guidelines are focused on outcomes important to key stakeholders and are evidence-based and properly implemented. MATERIALS AND METHODS: The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2023 updates were made using the Grading of Recommendations Assessment Development and Evaluation evidence-to-decision framework. This concerns formulating relevant clinical questions and important outcomes, conducting systematic reviews of the literature and meta-analyses where appropriate, completing summary of judgement tables, and writing recommendations that are specific, unambiguous and actionable, along with their transparent rationale. RESULTS: We herein describe the development of the 2023 IWGDF Guidelines on the prevention and management of diabetes-related foot disease, which consists of seven chapters, each prepared by a separate working group of international experts. These chapters provide guidelines related to diabetes-related foot disease on prevention; classification of diabetes-related foot ulcer, offloading, peripheral artery disease, infection, wound healing interventions, and active Charcot neuro-osteoarthropathy. Based on these seven guidelines, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. CONCLUSIONS: We believe that the adoption and implementation of the 2023 IWGDF guidelines by healthcare providers, public health agencies, and policymakers will improve the prevention and management of diabetes-related foot disease, and subsequently reduce the worldwide patient and societal burden caused by this disease.
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Pie Diabético , Enfermedades del Pie , Enfermedad Arterial Periférica , Humanos , Pie Diabético/etiología , Pie Diabético/prevención & control , Cicatrización de Heridas , Agencias InternacionalesRESUMEN
Diabetes-related foot disease results in a major global burden for patients and the healthcare system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-based guidelines on the prevention and management of diabetes-related foot disease since 1999. In 2023, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In addition, a new guideline on acute Charcot neuro-osteoarthropathy was created. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification and management of diabetes-related foot disease based on the seven IWGDF Guidelines. We also describe the organisational levels to successfully prevent and treat diabetes-related foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of healthcare professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes-related lower-extremity amputations. The burden of foot disease and amputations is increasing at a rapid rate, and comparatively more so in middle to lower income countries. These guidelines also assist in defining standards of prevention and care in these countries. In conclusion, we hope that these updated practical guidelines continue to serve as a reference document to aid healthcare providers in reducing the global burden of diabetes-related foot disease.
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Diabetes Mellitus , Pie Diabético , Enfermedades del Pie , Humanos , Pie Diabético/etiología , Pie Diabético/prevención & control , Agencias Internacionales , Amputación Quirúrgica , Diabetes Mellitus/prevención & controlRESUMEN
OBJECTIVE: To identify risk factors and assess diabetic foot ulcer (DFU) and amputation risk category (according to the 2015 International Working Group on the Diabetic Foot (IWGDF) guidance) among patients with type 2 diabetes in the Suez governorate, Egypt. METHOD: A cross-sectional study was conducted in the diabetic foot screening clinic of Suez General Hospital. A comprehensive sample of patients with type 2 diabetes attending the diabetes clinic every Saturday were enrolled in the study. Patients were divided into four groups according to their history and foot examination: without neuropathy (Group 0); with neuropathy (Group 1); with neuropathy associated with deformity and/or vascular disorders (Group 2); and with foot ulcer or amputation history (Group 3). RESULTS: A total of 220 patients were included in the study. Mean age of participants was 54.6±10.3 years and 70.5% of patients were female. The patients were divided into four groups: 37.3% were in group 0; 37.7% in group 1; 11.8% were in group 2; and 13.2% were in group 3. Male sex and diabetic complications (particularly neuropathy, cardiovascular disease and retinopathy) had the most significant effect on risk classification. CONCLUSION: This study showed that 62.7% of patients with diabetes enrolled in the study were at risk of developing a DFU and amputation. Physicians should conduct a foot assessment and risk categorisation for all patients with diabetes as early management or referral could prevent further complications.
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Diabetes Mellitus Tipo 2 , Pie Diabético , Úlcera del Pie , Adulto , Amputación Quirúrgica/efectos adversos , Estudios Transversales , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Pie Diabético/complicaciones , Pie Diabético/diagnóstico , Pie Diabético/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
Diabetic foot disease is a source of major patient suffering and societal costs. Investing in evidence-based international guidelines on diabetic foot disease is likely among the most cost-effective forms of health care expenditure, provided the guidelines are outcome focused, evidence based, and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2019 updates are based on formulating relevant clinical questions and outcomes, rigorous systematic reviews of the literature, and recommendations that are specific, and unambiguous along with their transparent rationale, all using the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework. We herein describe the development of the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease, which consists of six chapters, each prepared by a separate working group of international experts. These documents provide guidelines related to diabetic foot disease on prevention; offloading; peripheral artery disease; infection; wound healing interventions; and classification of diabetic foot ulcers. Based on these six chapters, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. We believe that adoption and implementation of the 2019 IWGDF guidelines by health care providers, public health agencies, and policymakers will result in improved prevention and management of diabetic foot disease and a subsequent worldwide reduction in the patient and societal burden this disease causes.
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Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Pie Diabético/prevención & control , Medicina Basada en la Evidencia , Guías de Práctica Clínica como Asunto/normas , Pautas de la Práctica en Medicina/normas , Conferencias de Consenso como Asunto , Pie Diabético/etiología , Pie Diabético/rehabilitación , Manejo de la Enfermedad , Humanos , Agencias Internacionales , Revisiones Sistemáticas como AsuntoRESUMEN
Diabetic foot disease results in a major global burden for patients and the health care system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In 2019, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification, and treatment of diabetic foot disease, based on the six IWGDF Guideline chapters. We also describe the organizational levels to successfully prevent and treat diabetic foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of health care professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes-related lower extremity amputations. We hope that these updated practical guidelines continue to serve as reference document to aid health care providers in reducing the global burden of diabetic foot disease.
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Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Pie Diabético/prevención & control , Guías de Práctica Clínica como Asunto/normas , Cicatrización de Heridas , Pie Diabético/etiología , Pie Diabético/rehabilitación , Manejo de la Enfermedad , Humanos , Revisiones Sistemáticas como AsuntoRESUMEN
BACKGROUND: Diabetic foot is an underestimated and redoubtable diabetes complication. The aims of our study were to assess diabetic foot ulcer risk factors according to International Working Group on the Diabetic Foot (IWGDF) classification, stratify patients into risk categories and identify factors associated with higher-risk grade. METHODS: Cross-sectional setting over a period of 07 months, patients were randomly selected from the diabetic outpatients attending our unit of diabetology. Questionnaire and clinical examination were made by the same physician. Patients free of active foot ulcer were included. RESULTS: Among 230 patients evaluated, 10 had an active foot ulcer and were excluded. Five patients (2.27%) had a history of foot ulcer and 3(1.36%) had a lower-limb amputation. Sensory neuropathy, as measured by the 5.07(10 g) Semmes-Weinstein monofilament testing, was present in 23.63% of patients, whereas 36.82% had a peripheral arterial disease based on clinical findings, and 43.63% had foot deformities. According to the IWGDF classification, Group 0: 72.72%, Group 1: 5.9%, Group 2: 17.73% and Group 3: 3.63%. After univariate analysis, patients in higher-risk groups were significantly more often female, had higher age and BMI, longer diabetes duration, elevated waist circumference, low school level, retinopathy and hyperkeratosis. Multivariate logistic regression analysis identified 3 significant independent factors associated with high-risk groups: retinopathy (OR = 2.529, CI95 [1.131-5.655], p = 0.024), hyperkeratosis (OR = 2.658, CI95 [1.222-5.783], p = 0.014) and school level (OR = 0.489, CI95 [0.253-9.44], p = 0.033). CONCLUSIONS: Risk factors for foot ulceration were rather common in outpatients with diabetes. The screening of patients at risk for foot ulceration should start early, integrated with sustainable patient education.
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Pie Diabético/diagnóstico , Pie Diabético/etiología , Adulto , Anciano , Amputación Quirúrgica/estadística & datos numéricos , Estudios Transversales , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiología , Diabetes Mellitus/cirugía , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/cirugía , Pie Diabético/epidemiología , Pie Diabético/cirugía , Neuropatías Diabéticas/diagnóstico , Neuropatías Diabéticas/epidemiología , Neuropatías Diabéticas/etiología , Neuropatías Diabéticas/cirugía , Femenino , Úlcera del Pie/diagnóstico , Úlcera del Pie/epidemiología , Úlcera del Pie/etiología , Úlcera del Pie/cirugía , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Medición de Riesgo , Factores de Riesgo , Factores Socioeconómicos , Túnez/epidemiologíaRESUMEN
In this 'Summary Guidance for Daily Practice', we describe the basic principles of prevention and management of foot problems in persons with diabetes. This summary is based on the International Working Group on the Diabetic Foot (IWGDF) Guidance 2015. There are five key elements that underpin prevention of foot problems: (1) identification of the at-risk foot; (2) regular inspection and examination of the at-risk foot; (3) education of patient, family and healthcare providers; (4) routine wearing of appropriate footwear; and (5) treatment of pre-ulcerative signs. Healthcare providers should follow a standardized and consistent strategy for evaluating a foot wound, as this will guide further evaluation and therapy. The following items must be addressed: type, cause, site and depth, and signs of infection. There are seven key elements that underpin ulcer treatment: (1) relief of pressure and protection of the ulcer; (2) restoration of skin perfusion; (3) treatment of infection; (4) metabolic control and treatment of co-morbidity; (5) local wound care; (6) education for patient and relatives; and (7) prevention of recurrence. Finally, successful efforts to prevent and manage foot problems in diabetes depend upon a well-organized team, using a holistic approach in which the ulcer is seen as a sign of multi-organ disease, and integrating the various disciplines involved.
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Angiopatías Diabéticas/terapia , Pie Diabético/prevención & control , Neuropatías Diabéticas/terapia , Medicina Basada en la Evidencia , Salud Global , Medicina de Precisión , Terapia Combinada/tendencias , Angiopatías Diabéticas/complicaciones , Angiopatías Diabéticas/fisiopatología , Pie Diabético/diagnóstico , Pie Diabético/etiología , Pie Diabético/terapia , Neuropatías Diabéticas/complicaciones , Neuropatías Diabéticas/fisiopatología , Diagnóstico Precoz , Salud Holística , Humanos , Agencias Internacionales , Grupo de Atención al Paciente/tendencias , Educación del Paciente como Asunto , Recurrencia , Índice de Severidad de la Enfermedad , Zapatos/efectos adversos , Infecciones de los Tejidos Blandos/complicaciones , Infecciones de los Tejidos Blandos/prevención & controlRESUMEN
Foot problems complicating diabetes are a source of major patient suffering and societal costs. Investing in evidence-based, internationally appropriate diabetic foot care guidance is likely among the most cost-effective forms of healthcare expenditure, provided it is goal-focused and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has been publishing and updating international Practical Guidelines since 1999. The 2015 updates are based on systematic reviews of the literature, and recommendations are formulated using the Grading of Recommendations Assessment Development and Evaluation system. As such, we changed the name from 'Practical Guidelines' to 'Guidance'. In this article we describe the development of the 2015 IWGDF Guidance documents on prevention and management of foot problems in diabetes. This Guidance consists of five documents, prepared by five working groups of international experts. These documents provide guidance related to foot complications in persons with diabetes on: prevention; footwear and offloading; peripheral artery disease; infections; and, wound healing interventions. Based on these five documents, the IWGDF Editorial Board produced a summary guidance for daily practice. The resultant of this process, after reviewed by the Editorial Board and by international IWGDF members of all documents, is an evidence-based global consensus on prevention and management of foot problems in diabetes. Plans are already under way to implement this Guidance. We believe that following the recommendations of the 2015 IWGDF Guidance will almost certainly result in improved management of foot problems in persons with diabetes and a subsequent worldwide reduction in the tragedies caused by these foot problems.
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Pie Diabético/terapia , Medicina Basada en la Evidencia , Salud Global , Guías de Práctica Clínica como Asunto , Terapia Combinada/tendencias , Consenso , Pie Diabético/prevención & control , Medicina Basada en la Evidencia/tendencias , Humanos , Agencias InternacionalesRESUMEN
OBJECTIVE: The aim was assessment of diabetic foot ulcer risk factors according to International Working Group on the Diabetic Foot (IWGDF) consensus. METHODOLOGY: All referred patients with diabetes were divided into four groups based on IWGDF criteria (without neuropathy, with neuropathy, neuropathy with deformity or vascular disorders, foot ulcer or amputation history). RESULTS: Mean age of patients was 53.8±10.7 years. Two hundred and sixty nine patients â(62/6%) were female and 161(37/4%) were male. Twenty three percent had disturbed sense of vibration, 26% had decreased sensitivity to monofilaments and 17% had decreased pain sensation. Ankle brachial index (ABI) was abnormal in 6%. About 7% had history of prior ulcer. Patients were classified into four risk groups according to IWGDF criteria. Two hundred and seventy seven patients (65%) were in group 0, 75(17%) in group 1, 47 (11%) in group 2 and 31 (7%) in group 3. Patients in higher-risk groups had higher age, longer diabetes duration, higher HbA1C and less training (p=0.0001, 0.001, 0.0001, 0.021 respectively). The risk was higher in the presence of retinopathy (p=0.005). Patient's sex, BMI, smoking and nephropathy did not have significant correlation with risk of diabetic foot ulcer. CONCLUSION: This study showed that increase of age, duration of diabetes and HbA1c, lack of training and presence of retinopathy increases the risk of diabetic foot ulcers.
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Objective: To assess the outcomes of diabetic foot infections (DFIs) due to Pseudomonas aeruginosa. Patients and Methods: From April 24, 2013 to July 31, 2016, we analyzed data from patients prospectively enrolled in our clinical pathway of DFIs, comparing those with infection due to Pseudomonas with those without infection due to Pseudomonas. Results: Overall, we assessed 1018 cases of DFIs: 392 with osteomyelitis and 626 with only soft tissue infections. The prevalence of P aeruginosa in deep wound cultures was 10% (104/1018); of the 1018 cultures, 22 were monomicrobial, 82 were polymicrobial, and 46 were with osteomyelitis. Overall, the patients were treated with a median of 1 surgical debridement and a total of 20 days of antibiotic therapy. In a comparison of crude groups, the proportion of clinical failures was significantly higher with Pseudomonas than with other pathogens (36/104 [35%] vs 218/914 [24%], respectively; P=.02). A multivariate analysis showed that pseudomonal DFIs did not recur more often than nonpseudomonal DFIs (hazard ratio, 1.0; 95% confidence interval, 0.6-1.7). Among the 104 cases of pseudomonal DFIs, there was no association between failure of treatment and the total duration of antibiotic therapy, duration of intravenous therapy, duration of combined antibiotic therapy with more than 1 agent, or duration of oral (fluoroquinolone) therapy. Among 15 cases of pseudomonal recurrence, 2 (13%) developed resistance to the antibiotic agent used for the index episode. Conclusion: For DFIs caused by P aeruginosa, other than choosing an antibiotic agent that is active against the organism, it does not appear necessary to treat with a different therapeutic regimen compared with the treatment of nonpseudomonal DFIs. There is no difference!
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Diabetic Foot Infection (DFI), in its severest form the acute infected 'diabetic foot attack', is a limb and life threatening condition if untreated. Acute infection may lead to tissue necrosis and rapid spread through tissue planes, in the patient with poorly controlled diabetes facilitated by the host status. A combination of soft tissue infection and osteomyelitis may co-exist, in particular if chronic osteomyelitis serves as a persistent source for recurrence of soft tissue infection. This "diabetic foot attack" is characterised by acutely spreading infection and substantial soft tissue necrosis. In the presence of ulceration, the condition is classified by the Infectious Diseases Society of America/International Working Group on the Diabetic Foot (IDSA/IWGDF Class 3 or 4) presentation requiring an urgent surgical intervention by radical debridement of the infection. Thus, 'time is tissue', referring to tissue salvage and maximal limb preservation. Emergent treatment is important for limb salvage and may be life-saving. We provide a narrative current treatment practices in managing severe DFI with severe soft tissue and osseous infection. We address the role of surgery and its adjuvants, the long term outcomes, potential complications and possible future treatment strategies.
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Foot problems complicating diabetes are a source of major patient suffering and societal costs. To prevent, or at least reduce, the adverse effects of foot problems in diabetes, the International Working Group on the Diabetic Foot (IWGDF; www.iwgdf.org) was founded in 1996, consisting of experts from almost all the disciplines involved in the care of patients with diabetes and foot problems. An important output of the IWGDF is the international consensus guidance, continuously updated since 1999. To date, the publications have been translated into 26 languages, and more than 100,000 copies have been distributed globally. The "Summary Guidance for Daily Practice" summarises the essentials of prevention and management of foot problems in persons with diabetes for clinicians who work with these patients on a daily basis. This guidance is the result of a long and careful process that started with the empaneling in 2013 of five working groups consisting of 49 international experts. These experts performed seven targeted systematic reviews to provide the evidence supporting the five chapters of the IWGDF Guidance on prevention; footwear and offloading; diagnosis, prognosis and management of peripheral artery disease; diagnosis and management of foot infections; interventions to enhance healing. In total almost 80,000 studies were detected by our literature review. After review of the title and abstract the reviewers of the different working groups selected only studies that fulfilled a minimal set of quality criteria and ended up with 429 articles for complete quality analysis. The GRADE system was used to translate the evidence from the studies into recommendations for daily clinical practice. The rating of each recommendation takes into account both the strength and the quality of the evidence. The IWGDF Guidance 2015 makes a total of 77 recommendations on prevention and management of foot problems in diabetes. These recommendations were condensed by the editorial board into this "Summary Guidance". Encouraging and aiding clinicians to follow the evidence-based recommendations of the IWGDF Guidance 2015, and in particular the principles outlined in the "Summary Guidance", will likely result in a worldwide reduction in, and better outcomes of, foot problems in persons with diabetes, helping to reduce the morbidity and mortality associated with this major health problem.