For information about individual topics, including any decisions affecting this guideline, see the summary table of prioritisation board decisions. Start by checking that Apple Music is installed on your smartphone or iPad and that you have an active Apple Music subscription. Then simply download and install the Apple Music Classical app on the same device and you’re all set. The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions. The recommendations aim to optimise antibiotic use and reduce antibiotic resistance.

• Local infection with signs of systemic inflammatory response (such as temperature of more than 38°C or less than 36°C, increased heart rate or increased respiratory rate).
• For a short explanation of why the committee did not change the recommendations that were reviewed in 2023, and how this might affect practice, see the rationale and impact section on assessing the risk of developing a diabetic foot problem.
• For example, from the formal Beethoven’s Piano Sonata No. 14 to the popular byname of Moonlight Sonata, or in multiple languages, such as Mondschein Sonata in German.
• In line with the NICE guideline on antimicrobial stewardship and Public Health England’s Start smart – then focus, the committee agreed that oral antibiotics should be used in preference to intravenous antibiotics where possible.
• These included if an infection was rapidly or significantly worsening or not improving, if other diagnoses were possible, or symptoms suggested a more serious illness or condition.

If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible. If you have a diabetic foot ulcer, your healthcare professional should check the size and depth of the ulcer and look for signs of infection and other problems. The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available.

Choice of antibiotic, dose frequency, route of administration and course length

• This guideline updates and replaces NICE guidelines CG10 (January 2004) and CG119 (March 2011), and the recommendation on foot care in NICE guideline CG15 (July 2004).
• The committee agreed to retain the recommendation from the 2015 guideline that antibiotics should be started as soon as possible if a diabetic foot infection is suspected.
• Reducing the frequency of foot assessments would mean reducing the number of chances to encourage good foot care and direct people to sources of support.
• These antibiotics may also be appropriate in other situations based on microbiological results and specialist advice.
• The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition.

These recommendations should ensure that appropriate reassessment is in place. But the antibiotics used in the studies were not wholly representative of UK practice, with some not being available in the UK and others not widely used. However, there were differences between some antibiotic classes, with lower rates of adverse effects generally for beta-lactam antibiotics. Local infection with erythema more than 2 cm around the ulcer or involving structures deeper than skin and subcutaneous tissues (such as abscess, osteomyelitis, septic arthritis or fasciitis), and no systemic inflammatory response signs.

Evidence summaries (

Foot assessments are currently part of the annual diabetes review, so it makes sense to continue to include the foot check and risk assessment in that appointment. There are also Quality and Outcomes Framework (QOF) indicators for annual foot examination and risk classification, which further justify retaining the current system. Base antibiotic course length on the severity of the infection and a clinical assessment of response to treatment. Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does gen z alphabet not require intravenous antibiotics. We reviewed this guideline and will update the recommendations on treatment for diabetic foot ulcer in specific relation to considering topical oxygen therapy.

The committee agreed that in people with diabetes, all foot wounds are likely to be colonised with bacteria. However, for people with a diabetic foot infection, prompt treatment of the infection is important to prevent complications, including limb-threatening infections. The evidence showed that 95.5% of people assessed as low risk at their first clinical assessment remained in the low-risk group at their final assessment 8 years later.

Why the committee made the recommendation

But Apple Music will also offer the world’s largest classical audio catalogue along with hundreds of handpicked classical playlists. Classical music often involves multiple musicians recording works that have been recorded many times before and are referred to by different names. For example, from the formal Beethoven’s Piano Sonata No. 14 to the popular byname of Moonlight Sonata, or in multiple languages, such as Mondschein Sonata in German. Such complexities mean that classical music fans have been ill-served by streaming platforms.

Assessing the risk of developing a diabetic foot problem

These sections briefly explain why the committee made the recommendations and how they might affect practice. Local infection with signs of systemic inflammatory response (such as temperature of more than 38°C or less than 36°C, increased heart rate or increased respiratory rate). Skin takes some time to return to normal, and full resolution of symptoms after a course of antibiotics is not expected. The treatment will depend on how severe the ulcer is, where it is, and what you would prefer.

The committee agreed that the most important factor for an assessment tool was the ability to accurately identify people who are at high risk of developing a diabetic foot ulcer. Accurate identification allows people to be referred to appropriate services, where monitoring and preventative treatment can be started. A focus on high sensitivity over high specificity may lead to more false positives, with more people incorrectly receiving increased monitoring and referral to specialist services. However, the committee believe that this is preferable to using a system with lower sensitivity, because an increased risk of ulcer, infection and amputation is much worse than wasted resources from unnecessary monitoring or referrals. Overall, the SIGN system showed the highest sensitivity for both high-risk and combined high- and moderate-risk groups. When prescribing antibiotics for a suspected diabetic foot infection in adults aged 18 years and over, follow table 1 for a mild infection or table 2 for amoderate or severe infection.

The committee agreed that a shorter course was generally as effective as a longer course for adults with a mild diabetic foot infection, and a 7‑day course was sufficient for most people. However, it agreed that a longer course (up to a further 7 days) may be needed for some people based on a clinical assessment of their symptoms and history. They discussed the limited evidence on antibiotic course length, which compared 6 weeks with 12 weeks in adults with diabetic foot osteomyelitis.

Advice

The committee also discussed factors that would indicate that a person with a diabetic foot infection would need to be reassessed. These included if an infection was rapidly or significantly worsening or not improving, if other diagnoses were possible, or symptoms suggested a more serious illness or condition. The committee based the recommendation on their experience and safety netting advice from the NICE guideline on antimicrobial stewardship. They agreed that if symptoms worsened rapidly or significantly at any time, or did not improve within 1 to 2 days, people with a diabetic foot infection should be advised to seek medical help.

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE’s information on making decisions about your care. For information on related topics see our cardiometabolic disease prevention and treatment summary page.

For moderate or severe infection, the committee recommended flucloxacillin at a dose of 1 g four times a day. Based on evidence, their experience and resistance data, the committee agreed that flucloxacillin is an effective empirical antibiotic for mild diabetic foot infections (with dosing taking account of a person’s body weight and renal function). The committee agreed that in their experience, the incidence of diabetic foot infections in children and young people is rare. The mean age of participants in the evidence considered ranged from 54 to 64 years. Based on these factors, the committee included an antibiotic prescribing table for adults, but not for children and young people.

Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. We use the best available evidence to develop recommendations that guide decisions in health, public health and social care. Patient preference is also important, particularly for treatment that will involve a hospital stay or be prolonged.

For a short explanation of why the committee made these 2019 recommendations and how they might affect practice, see the rationale and impact section on treatment. The 2015 guideline recommended a modified version of SIGN that includes a check for renal disease. The committee agreed that this modification is useful and should be retained, because renal disease is a known risk factor for diabetic foot problems. For a short explanation of why the committee made this 2019 recommendation and how it might affect practice, see the rationale and impact section on advice. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. This guideline updates and replaces NICE guidelines CG10 (January 2004) and CG119 (March 2011), and the recommendation on foot care in NICE guideline CG15 (July 2004).

Diabetic foot infection

There were no significant differences in classification accuracy (assessed using c‑statistics) between the different risk assessment tools. When considering classification accuracy, sensitivity and specificity together, the PODUS and SIGN systems were the best. PODUS had a higher c‑statistic than SIGN, but it did not report sensitivity or specificity. ‘Diabetic foot problem’ refers to any problem affecting the feet in people with diabetes that is caused by loss of sensation (peripheral sensory neuropathy) and/or circulation problems (peripheral arterial disease). These antibiotics may also be appropriate in other situations based on microbiological results and specialist advice. Other antibiotics may be appropriate based on microbiological results and specialist advice.