Antimicrobial stewardship pathway

Diabetes-related foot ulcers

Assess

Perform holistic patient and wound assessment with TIMERS¹⁻¹²

Is the wound infected? Do you observe two or more clinical signs and symptoms?

Urgently consult vascular team and IDT in exposed bone/tendon, osteomyelitis (MRI/x-ray) or CLTI (TBPI <0.4)

Contamination

Microorganisms present
No host reaction
No clinical signs
No delayed healing
No proliferation

Colonisation

Microorganisms present
No host reaction
No clinical signs
No delayed healing
Limited proliferation

Covert local infection

Hypergranulation
Bleeding, friable granulation tissue
Epithelial bridging and pocketing
Increasing exudate
Delayed healing

Overt local infection

New/increasing pain
Erythema or changed skin tone
Swelling
Increasing malodour
Purulent discharge
Increased exudate
Local warmth
Wound breakdown and enlargement

Spreading infection

Spreading erythema (>2cm from wound edge)
Extended induration
Crepitus
Wound breakdown
Lymphangitis

Systemic infection

Malaise
Lethargy
Loss of appetite
Pyrexia/fever
Sepsis
Septic shock
Organ failure

Increasing microbial burden in wound

Consider signs and symptoms of biofilm: covert infection, recurrent infections, low-level chronic inflammation/erythema or antimicrobial treatment failure⁵

Consider signs of sepsis⁶

Signs of sepsis²⁴

Sepsis is a life-threatening condition in which the body's response to infection causes injury to its tissues and organs. Organ dysfunction is a key component in any diagnosis of sepsis.

Act on any of the following red flags:

S. Slurred speech or confusion

E. Extreme shivering or muscle pain

P. Passing no urine (in a day)

S. Severe breathlessness

I. It feels like you are going to die

S. Skin mottled or discoloured

IDSA/IWGDF uninfected¹²

IDSA/IWGDF mild–moderate¹²

IDSA/IWGDF severe¹²

Treat

Perform wound bed preparation (therapeutic cleansing, debridement and repeat cleansing)¹⁰⁻¹⁶

Is there a need for a dressing for infection control or treatment?

Control microbial burden in wound contamination or colonisation

First-line: Microbial-binding dressings¹⁷⁻²⁴*

Treat covert or overt local wound infection

Referral: Consider specialist referral
First-line: Microbial-binding dressings¹⁷⁻²⁴*
Second-line: Antiseptic dressings¹

Treat spreading or systemic wound infection

Referral: Surgical referral
Culture: Swab or tissue/bone sample^{1, 12}
Antibiotics: Targeted systemic antibiotics (longer and stronger in osteomyelitis) used with dressings^{1, 12, 25}
First-line: Microbial-binding dressings¹⁷⁻²⁴*
Second-line: Antiseptic dressings¹

Review

Notes

*Microbial-binding dressings have a DACC coating that can control microbial burden to prevent or manage infection in a way that is not expected to contribute to antimicrobial resistance. All treatments should be used per local policy and where clinically appropriate. See below for supplementary tables and references.

Abbreviations

CLTI=critical limb-threatening Ischaemia; CRP=C-reactive protein; DACC=dialkylcarbamoyl chloride; ESR=erythrocyte sedimentation rates; IDSA=Infectious Diseases Society of America; IDT=interdisciplinary team; IWGDF=International Working Group on the Diabetic Foot; TBPI=toe brachial pressure index; TIMERS=Tissue, Infection/Inflammation, Moisture balance, Edge/epithelialisation, Regeneration and repair, Social factors

Aspects of a holistic patient assessment in diabetes-related foot ulceration

– adapted from TIMERS^{1-5, 7-12}

Patient assessment

Comorbidities
Current medication
Functionality and mobility
Nutritional assessment
Skin assessment (including skin tone)
Social factors
Surgical and medical history

Foot assessment

Neuropathic assessment
Oedema
Pallor
Pulses
Skin perfusion
Skin temperature
TBPI/toe systolic pressure
Transcutaneous oxygen pressure
Vitals

Wound assessment

Charcot foot
DFU stage (Wagner, Texas, SINBAD or WIfI)
Imaging as appropriate (CT, MRA, duplex)
Location, duration, size and depth
Odour
Pain (nociceptive or neuropathic)
Periwound condition
Previous investigations and treatments
Tissue types on wound bed (necrotic, sloughy, granulation or epithelial)

Risk factors for wound infection

– adapted from the International Wound Infection Institute¹ ²⁵⁻⁴⁷

Patient risk factors

Acute kidney injury/disease
Alcohol, smoking or illicit drug use
Conditions associated with hypoxia or poor perfusion
Connective tissue disorders (e.g. Ehlers-Danlos syndrome)
Corticosteroid use
Immune disorders (e.g. acquired immune deficiency syndrome)
Lymphoedema
Malnutrition or obesity
Neuroarthropathy
New/worsening azotaemia and electrolyte abnormalities
Peripheral arterial disease (inc. ischaemia)
Peripheral neuropathy (sensory, motor and autonomic)
Poor adherence to treatment plan
Poorly controlled diabetes
Radiation therapy or chemotherapy
Severe/worsening hyperglycemia or acidosis

Wound risk factors

Duration of wound
Foreign body presence (e.g. drains, sutures or wound dressing fragments)
Haematoma
Impaired tissue perfusion
Increased exudate and oedema that is not adequately managed
Large or deep wounds
Necrotic or sloughy wound tissue
Penetration to subcutaneous tissues (fascia, tendon, muscle, joint or bone)
Previous ulceration or amputation
Probing to bone
Traumatic aetiology
Wounds over bony prominences

Environmental risk factors

Hospitalisation (due to increased risk of exposure to antimicrobial-resistant microorganisms)
Inadequate hand hygiene and aseptic technique
Inadequate management of moisture (e.g. due to exudate, incontinence or perspiration)
Interface pressure that is inadequately offloaded
Unhygienic environment (e.g. dust, unclean surfaces, or presence of mould/mildew)

Signs of sepsis⁶

Sepsis is a life-threatening condition in which the body's response to infection causes injury to its tissues and organs. Organ dysfunction is a key component in any diagnosis of sepsis.

Act on any of the following red flags:

S. Slurred speech or confusion

E. Extreme shivering or muscle pain

P. Passing no urine (in a day)

S. Severe breathlessness

I. It feels like you are going to die

S. Skin mottled or discoloured

Guidance

Treece et al (2023)

SINBAD classification

Bus et al (2024)

IWGDF guidelines on offloading foot ulcers in persons with diabetes

Chen (2024)

IWGDF guidelines on interventions to enhance healing of foot ulcers in people with diabetes

El-Sayed et al (2025)

American Diabetes Association standards of care in diabetes

Fitridge et al (2024)

Intersocietal guidelines on peripheral artery disease in people with diabetes and a foot ulcer

International Wound Infection Institute (2022)

Wound infection in clinical practice

Mills et al (2014)

WIfI classification

Monterro-Soares et al (2024)

IWGDF guidelines on the classification of foot ulcers in people with diabetes

DACC™-coated dressings instructions for use

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diabetes-related foot ulcers

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click for REFERENCES

International Wound Infection Institute. Wound infection in clinical practice: principles of best practice – Wounds International. 2022.
Atkin L et al. J Wound Care. 2019;28:S1–50.
Fletcher J et al. Wounds UK. 2018;1–24.
Conte MS et al. Eur J Vasc Endovasc Surg.2019;58:S1–S109.
Schultz GS et al. Wound Rep Regen. 2017;25:744–757.
UK Sepsis Trust. Spotting the signs of sepsis. 2025.
Wagner FW. Foot Ankle. 1981;2:64–122.
Mills JL et al. J Vasc Surg. 2014;59:220–234.
Treece KA. Diabet Med. 2004;21:987–991.
El Sayed NA et al. Diabetes Care. 2025;48:S252–S265.
Fitridge R et al. Diabetes Metab Res Rev. 2024;40:e3686.
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Bus SA et al. Diabetes Metab Res Rev. 2024;40:e3647.
Chen P et al. Diabetes Metab Res Rev. 2024;40:e3644.
Haesler E et al. Wounds Int. 2025;1–52.
Schultz GS et al. Wound Rep Regen. 2003;11:S1–28.
Johansson A et al. J Wound Care. 2009;18:470–473.
Ma.as CR et al. J Wound Care. 2025;34:278–284 .
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Technol. 2024;1:28–37.
Bjarnsholt T et al. Wounds Int. 2020;1–32.
Blackburn J et al. Int Wound J. 2025;22:e70684.
Cole W et al. Wounds. 2025;37:S1–S24.
Rippon MG et al. J Wound Care. 2021;30:284–296.
Assadian O et al. J Wound Care. 2023;32:3–4.
Garc.a Nores GD et al. J Invest Dermatol. 2018;138:325–335.
Brocklehurst JD et al. Adv Skin Wound Care. 2023;36:1–5

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