In the early 2000s, the Infectious Diseases Society of America (IDSA) commissioned the development of a new clinical practice guideline (CPG) for the treatment of diabetic foot infections (DFI). As an elected Fellow of the IDSA, I was honored to be invited to be a participant in that committee co-chaired by Benjamin Lipsky, MD and Anthony Berendt, MD, two of the top infectious disease specialists in the world in the area of DFI. After numerous meetings and telephone conferences, we published our first document in 2004.¹ Much to the surprise of everyone, this DFI guideline became the most downloaded CPG from the IDSA's website www.idsociety.org. This despite there being guidelines on many other types of infectious diseases that, one could argue, made up more of the “bread and butter” practice of the average infectious disease physician.

Because of the success of the original DFI CPG and changes in technology and antibiotic therapy, the Society asked for an update of the CPG. After roughly three years of work and multiple rounds of both internal and external review, an updated document was published in 2012.² The popularity of this guideline continues to this day. As of September 2015, the updated 2012 article has been referenced in the world literature over 1450 times! (Personal communication with Dr. Ben Lipsky.) Fewer than 0.01% of all scientific papers are referenced greater than 1000 times.

The full 42 page guideline can be found here.

This CPG contains 44 evidence-based recommendations that attempt to answer ten of the most common questions on the diagnosis and treatment of DFI. It is structured, as are all current IDSA Guidelines, in a question, recommendation, evidence summary format. Just a few of the questions include:

• How should I assess a diabetic patient presenting with a foot infection?
• How should I diagnose and treat osteomyelitis?
• When and how should I obtain specimens for culture?
• How should I select and when should I modify an antibiotic regimen?

In order to make the information accessible to the reader, notice that the questions are phrased in a “conversational” manner. Likewise, the reader will find that the recommendations are provided in a similar fashion (ie, “We recommend that…”). Likewise, the level of evidence is provided using the GRADE (Grading of Recommendations Assessment, Development and Evaluation found at www.gradeworkinggroup.org/) system, which pairs an evaluation of the strength of a recommendation with the quality of the evidence. For example, a rating of “Strong, Low” is defined as there being a strong recommendation but based on low quality of evidence. By using this system, it avoids confusing terminology common in the past such as “this is level 3B evidence”, a system which most readers have difficulty remembering.

Possibly the most enduring legacy of both the 2004 and 2012 documents was our development of a DFI infection severity scale. Unlike some of the myriad of wound scoring systems that are currently in the literature that deal primarily with the size and depth of a particular wound, the IDSA system is strictly based on the severity of the infection. Instead of using complicated, difficult to remember alpha numeric rankings (“this is a grade II A wound”), our system simply consists of four levels: The wound is uninfected or has a mild, moderate or severe infection. The clinical definition of each of these can be found in the full document or in my PRESENT lecture on this topic, entitled “Diabetic Foot Infections – IDSA Guidelines”.

1. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew DP, Mader JT, Norden C, Tan JS. IDSA Guideline: Diagnosing and Treating Diabetic Foot Infections. Clinical Infectious Diseases. 2004;39(7)885-910.
2. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Pinzur M, Senneville E. 2012 IDSA Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases. 2012;54(12):132–173.