Updated IDSA Guidelines On DFIs Emphasize Appropriate Antibiotic Use
By Brian McCurdy, Senior Editor
The Infectious Diseases Society of America (IDSA) has released its latest guidelines for diabetic foot infections, updating the recommendations from 2004.
The guidelines primarily urge clinicians to determine if a diabetic foot wound is clinically infected and to avoid prescribing antibiotics for the approximately 50 percent of wounds that are clinically uninfected, according to Benjamin Lipsky, MD, FIDSA, the lead author of the IDSA guidelines.
Dr. Lipsky notes it is sufficient to use narrow-spectrum therapy aimed only at staphylococci and streptococci for most acute mild or moderate diabetic foot infections in patients who have not recently received antibiotics. He says one can usually reserve broader spectrum empiric therapy for severe infections or patients who have failed previous antibiotic therapy.
Dr. Lipsky adds that the duration of antibiotic therapy rarely needs to last for more than one or two weeks for most soft tissue infections although it may need to be longer for unresected osteomyelitis.
“The key issue is we have to continue to start broad and get more narrow” with antibiotic coverage, notes David G. Armstrong, DPM, PhD, MD, a co-author of the guidelines. “However … I think we’re going to be moving from Louis Pasteur-based microbiology to CSI-based microbiology where we’re moving away from just plating everything on a petri dish toward actual molecular diagnosis.”
Such molecular diagnosis will over the coming years speed up assessments but Dr. Armstrong says this will also most likely show a “massive difference” in the kinds of bacteria and the amount of bacteria clinicians see in diabetic foot infections. Clinicians will be looking at the whole microbiome rather than the individual bacteria, notes Dr. Armstrong, a Professor of Surgery at the University of Arizona College of Medicine and the Director of the Southern Arizona Limb Salvage Alliance.
“Whether this difference on the diagnostic side makes a massive difference clinically remains to be seen but it is exciting nonetheless,” adds Dr. Armstrong.
The main changes to the guidelines since 2004 entailed the use of a new format of asking key questions, answering them and providing the evidence base for the recommendations, notes Dr. Lipsky, a Professor of Medicine at the University of Washington and the Director of the Primary Care Clinic at the Veterans Affairs Puget Sound in Washington. He also points out the use of the GRADE system to grade the quality and strength of the recommendations.
Although most of the basic principles in the 2012 and 2004 guidelines are the same, Dr. Lipsky notes that the authors added 345 references (mostly published since the last guidelines). He says they provide “far more evidence” for the recommendations and information on newly published papers on antibiotic therapy for diabetic foot infections. Dr. Armstrong also praises the abundance of research in the updated guidelines, noting that the last 10 years have seen a greater than 80 percent increase in the number of studies on the diabetic foot.
Dr. Armstrong notes that the implementation of the diabetic foot infection guidelines may be able to save costs in hospitals. “I think (these guidelines will have) a real economic impact as well as a pragmatic and scientific impact for our patients,” notes Dr. Armstrong.
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