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Summary for primary care

Diabetic Foot Problems: Prevention and Management

Latest Guidance Update

January 2023: NICE reviewed recent evidence and decided that no changes were needed to its guidance on risk assessment tools for diabetic foot problems and frequency of diabetic foot reviews.

Overview

This Guidelines summary covers preventing and managing foot problems in children, young people, and adults with diabetes. This summary contains recommendations relevant to primary care; refer to the full guideline for the complete set of recommendations.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Assessing the Risk of Developing a Diabetic Foot Problem

Frequency of Assessments

  • For children with diabetes who are under 12 years, give them, and their family members or carers (as appropriate), basic foot care advice.
  • For young people with diabetes who are 12 to 17 years, the paediatric care team or the transitional care team should assess the young person’s feet as part of their annual assessment, and provide information about foot care. If a diabetic foot problem is found or suspected, the paediatric care team or the transitional care team should refer the young person to an appropriate specialist.
  • For adults with diabetes, assess their risk of developing a diabetic foot problem at the following times:
    • When diabetes is diagnosed, and at least annually thereafter.
    • If any foot problems arise.

Assessing the Risk of Developing a Diabetic Foot Problem

  • When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings, and examine both feet for evidence of the following risk factors:
    • neuropathy (use a 10 g monofilament as part of a foot sensory examination)
    • limb ischaemia (see the NICE guideline on peripheral arterial disease)
    • ulceration
    • callus
    • infection and/or inflammation
    • deformity
    • gangrene
    • Charcot arthropathy.
  • Use ankle brachial pressure index in line with the NICE guideline on peripheral arterial disease. Interpret results carefully in people with diabetes because calcified arteries may falsely elevate results.
  • Assess the person’s current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification:
    • Low risk:
      • no risk factors present except callus alone.
    • Moderate risk:
      • deformity or
      • neuropathy or
      • peripheral arterial disease.
    • High risk:
      • previous ulceration or
      • previous amputation or
      • on renal replacement therapy or
      • neuropathy and peripheral arterial disease together or
      • neuropathy in combination with callus and/or deformity or
      • peripheral arterial disease in combination with callus and/or deformity.
    • Active diabetic foot problem:
      • ulceration or
      • infection or
      • chronic limb-threatening ischaemia or
      • gangrene or
      • suspicion of an acute Charcot arthropathy, or an unexplained hot, swollen foot with a change of colour, with or without pain.

Managing the Risk of Developing a Diabetic Foot Problem

  • For people who are at low risk of developing a diabetic foot problem:  
    • continue to carry out annual foot assessments
    • emphasise the importance of foot care
    • advise them that they could progress to moderate or high risk.
  • Refer people who are at moderate or high risk of developing a diabetic foot problem to the foot protection service.
  • The foot protection service should assess newly referred people as follows:
    • Within 2 to 4 weeks for people who are at high risk of developing a diabetic foot problem.
    • Within 6 to 8 weeks for people who are at moderate risk of developing a diabetic foot problem.
  • For people at moderate or high risk of developing a diabetic foot problem, the foot protection service should:
    • Assess the feet.
    • Give advice about, and provide, skin and nail care of the feet.
    • Assess the biomechanical status of the feet, including the need to provide specialist footwear and orthoses.
    • Assess the vascular status of the lower limbs.
    • Liaise with other healthcare professionals, for example, the person’s GP, about the person’s diabetes management and risk of cardiovascular disease.
  • Depending on the person’s risk of developing a diabetic foot problem, carry out reassessments at the following intervals:
    • Annually for people who are at low risk, as part of their annual diabetes review.
    • Frequently (for example, every 3 to 6 months) for people who are at moderate risk.
    • More frequently (for example, every 1 to 2 months) for people who are at high risk, if there is no immediate concern.
    • Very frequently (for example, every 1 to 2 weeks) for people who are at high risk, if there is immediate concern.
  • Consider more frequent reassessments for people who are at moderate or high risk, and for people who are unable to check their own feet.

Patient Information About the Risk of Developing a Diabetic Foot Problem

  • Provide information and clear explanations to people with diabetes and/or their family members or carers (as appropriate) when diabetes is diagnosed, during assessments, and if problems arise. Information should be oral and written, and include the following:
    • Basic foot care advice and the importance of foot care.
    • Foot emergencies and who to contact.
    • Footwear advice.
    • The person’s current individual risk of developing a foot problem.
    • Information about diabetes and the importance of blood glucose control (also see recommendation below).
  • For guidance on education programmes and information about diabetes, see the education and information section in the NICE guideline on type 1 diabetes in adults, the education section in the NICE guideline on type 2 diabetes in adults, and the sections on education and information for children and young people with type 1 diabetes and education information for children and young people with type 2 diabetes in the NICE guideline on diabetes in children and young people.

Diabetic Foot Problems

Referral

  • If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services and inform the multidisciplinary foot care service (according to local protocols and pathways), so they can be assessed and an individualised treatment plan put in place. Examples of limb-threatening and life-threatening diabetic foot problems include the following:
    • Ulceration with fever or any signs of sepsis.
    • Ulceration with limb ischaemia (see the NICE guideline on peripheral arterial disease).
    • Clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration).
    • Gangrene (with or without ulceration).
  • For all other active diabetic foot problems, refer the person within 1 working day to the multidisciplinary foot care service or foot protection service (according to local protocols and pathways) for triage within 1 further working day.

Patient Information about Diabetic Foot Problems

  • Provide information and clear explanations as part of the individualised treatment plan for people with a diabetic foot problem. Information should be oral and written, and include the following:
    • A clear explanation of the person’s foot problem.
    • Pictures of diabetic foot problems.
    • Care of the other foot and leg.
    • Foot emergencies and who to contact.
    • Footwear advice.
    • Wound care.
    • Information about diabetes and the importance of blood glucose control (also see the second recommendation in the section, Patient Information About the Risk of Developing a Diabetic Foot Problem).
  • If a person presents with a diabetic foot problem, take into account that they may have an undiagnosed, increased risk of cardiovascular disease that may need further investigation and treatment. For guidance on the primary prevention of cardiovascular disease, see the NICE guideline on cardiovascular disease: risk assessment and reduction, including lipid modification.

Diabetic Foot Ulcer

Investigation

  • If a person has a diabetic foot ulcer, assess and document the size, depth and position of the ulcer.
  • Use a standardised system to document the severity of the foot ulcer, such as the SINBAD (Site, Ischaemia, Neuropathy, Bacterial Infection, Area and Depth) or the University of Texas classification system.
  • Do not use the Wagner classification system to assess the severity of a diabetic foot ulcer.
For recommendations on the treatment of diabetic foot ulcer, refer to the full guideline.

Diabetic Foot Infection

For recommendations on the investigation of diabetic foot infection, refer to the full guideline.

Algorithm 1: Diabetic Foot Infection—Antimicrobial Prescribing

© NICE, 2023. All rights reserved. Subject to Notice of rights. Reproduced with permission.

Treatment

  • Start antibiotic treatment for people with suspected diabetic foot infection as soon as possible. Take samples for microbiological testing before, or as close as possible to, the start of antibiotic treatment.
  • When choosing an antibiotic for people with a suspected diabetic foot infection (see the section on choice of antibiotic), take account of:
    • the severity of diabetic foot infection (mild, moderate or severe).
    • the risk of developing complications.
    • previous microbiological results.
    • previous antibiotic use.
    • patient preferences.

Choice of Antibiotic

  • When prescribing antibiotics for a suspected diabetic foot infection in adults aged 18 years and over.
  • Seek specialist advice when prescribing antibiotics for a suspected diabetic foot infection in children and young people under 18 years.
  • Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.
  • If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.
  • Base antibiotic course length on the severity of the infection and a clinical assessment of response to treatment. Review the need for continued antibiotics regularly.
For more information on antibiotic choice, refer to the full guideline.

Advice

  • When prescribing antibiotics for a diabetic foot infection, give advice about:
    • possible adverse effects of the antibiotic(s)
    • seeking medical help if symptoms worsen rapidly or significantly at any time, or do not start to improve within 1 to 2 days.

Reassessment

  • When microbiological results are available:
    • review the choice of antibiotic and
    • change the antibiotic according to results, using a narrow-spectrum antibiotic, if appropriate.
  • Reassess people with a suspected diabetic foot infection if symptoms worsen rapidly or significantly at any time, do not start to improve within 1 to 2 days, or the person becomes systemically very unwell or has severe pain out of proportion to the infection. Take account of:
    • other possible diagnoses, such as pressure sores, gout or non-infected ulcers
    • any symptoms or signs suggesting a more serious illness or condition, such as limb ischaemia, osteomyelitis, necrotising fasciitis or sepsis
    • previous antibiotic use.

Prevention

  • Do not offer antibiotics to prevent diabetic foot infections. Give advice about seeking medical help if symptoms of a diabetic foot infection develop.

For recommendations on care across all settings and Charcot arthropathy, refer to the full guideline.


References


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