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endo.diabetes-related-foot-disease.v1PRODUCTION
endo.diabetes-related-foot-disease.v1

Diabetes-related foot disease (ulcer, infection, osteomyelitis)

endocrinologychronicacutesubacuteadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Assess for ulcer (with/without infection), Charcot, ischemia, neuropathy; establish chronic foot risk class (IWGDF 0–3)

Inputs
3
Actions
0
Advance rule
Set
Advance when

risk class + acute pathway documented

Patient inputs (16)

Age + diabetes duration drive complication burden + revascularization candidacy (IWGDF 2023)

T1 vs T2; duration informs neuropathy + vascular disease likelihood (IWGDF 2023; ADA 2026)

Highest predictor of new ulcer / amputation (IWGDF 2023)

Smoking cessation is critical for healing and vascular outcomes (IWGDF 2023; ADA 2026)

IWGDF / SINBAD / WIfI staging — size, depth, location, ischemia, neuropathy, infection (IWGDF 2023)

PTB positive predicts osteomyelitis (LR ~7) (IDSA 2012 Lipsky)

Glycemic control benchmark; A1c <8% target for ulcer healing (ADA 2026)

Renal function — antibiotic dosing, contrast for angiography, CKD stage (IWGDF 2023)

Leukocytosis suggests infection severity (often blunted in diabetes) (IDSA 2012 Lipsky)

CRP and ESR for infection / osteomyelitis follow-up; ESR >70 supports osteo (IDSA 2012 Lipsky)

Deep tissue or bone culture preferred over swab — drives antibiotic targeting (IDSA 2012 Lipsky)

First imaging — bone resorption, gas, foreign body, fracture / Charcot (IWGDF 2023)

PAD assessment — ABI <0.9 PAD; <0.4 CLTI; ABI may be falsely elevated in calcified vessels — use TBI or TcPO2 (IWGDF 2023)

Fever, hypotension, tachycardia, AMS = systemic; informs IDSA severity (mild / moderate / severe) (IDSA 2012 Lipsky)

Antibiotic allergies; renal-dose adjustments; interactions (warfarin, sulfonylureas with TMP-SMX) (IDSA 2012 Lipsky)

Best imaging for osteomyelitis vs Charcot; soft-tissue abscess (IDSA 2012 Lipsky; IWGDF 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningsystemic_infection_or_sepsis (IDSA 2012 Lipsky)
    Systemic signs of infection (fever, hypotension, tachycardia, AMS, leukocytosis) in DFI (IDSA 2012 Lipsky)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnecrotizing_soft_tissue_or_gas (IDSA 2012 Lipsky)
    Crepitus, gas in tissue, rapidly spreading erythema, severe pain out of proportion (IDSA 2012 Lipsky)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereosteomyelitis_confirmed (IDSA 2012 Lipsky)
    Probe-to-bone positive AND MRI / bone biopsy confirms osteomyelitis (IDSA 2012 Lipsky; IWGDF 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecritical_limb_threatening_ischemia (IWGDF 2023)
    Rest pain, non-healing ulcer, gangrene + ABI <0.4 OR TBI <0.3 OR TcPO2 <30 (IWGDF 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecharcot_foot_acute (IWGDF 2023)
    Hot, swollen, red foot in patient with neuropathy, often without preceding ulcer; X-ray may show fracture / dislocation (IWGDF 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapid_glycemic_decompensation_with_dfi (ADA 2026)
    Severe hyperglycemia, DKA, or HHS in setting of foot infection (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefailed_outpatient_therapy (IDSA 2012 Lipsky)
    IDSA mild/moderate DFI not improving after 1-2 wk PO antibiotics + offloading (IDSA 2012 Lipsky)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

IDSA / IWGDF 2023 — severity-tiered empirical antibiotic regimen for diabetic foot infection
axis: dfi_idsa_severity_tierstep 1 - Tier 1 — Mild infection (superficial, no systemic signs, ≤2 cm cellulitis, no significant ischemia)
Selected step "Tier 1 — Mild infection (superficial, no systemic signs, ≤2 cm cellulitis, no significant ischemia)" — IDSA mild — duration 1–2 weeks PO; target Staph aureus + β-hemolytic streptococci
  • cephalexin
    first line
    cephalosporin_1st_gen
    500 mg PO QID • PO • q6h × 7–14 days
    triggers: mild_DFI_no_MRSA_risk
    IDSA 2023 — first-line MSSA/strep coverage
    rxcui 2231
  • dicloxacillin
    first line
    penicillin_anti_staph
    500 mg PO QID • PO • q6h × 7–14 days
    triggers: mild_DFI_no_MRSA_risk
    IDSA — alternative anti-staph penicillin
    rxcui 3356
  • clindamycin
    second line
    lincosamide
    300–450 mg PO QID • PO • q6h × 7–14 days
    triggers: penicillin_allergy, MRSA_risk_low_local_resistance
    PCN-allergic; check local D-test for inducible MRSA resistance
    rxcui 2582
  • doxycycline
    second line
    tetracycline
    100 mg PO BID • PO • q12h × 7–14 days
    triggers: MRSA_risk, penicillin_allergy
    IDSA — covers CA-MRSA + good tissue penetration
    rxcui 3640
  • trimethoprim-sulfamethoxazole
    second line
    folate_inhibitor
    1 DS tab (160/800) PO BID • PO • q12h × 7–14 days
    triggers: MRSA_risk, penicillin_allergy
    IDSA — covers CA-MRSA; renal dose; SJS warning + warfarin/sulfonylurea interactions
    rxcui 10831

outpatient playbook — drug actions (4)

  1. 1. cephalexin OR dicloxacillin OR clindamycin / doxycycline / TMP-SMX
    Per IDSA mild • PO • 7–14 days
    trigger: IDSA mild infection
    IDSA 2023 first-line + alternatives
  2. 2. amoxicillin-clavulanate OR cipro+metro
    Per IDSA moderate • PO • 14–28 days
    trigger: IDSA moderate
    Broader Gram-negative + anaerobic
  3. 3. aspirin 81 mg + statin
    ASA 81 mg + atorvastatin 40–80 mg • PO • daily
    trigger: ASCVD/PAD
    Secondary prevention
  4. 4. optimized glycemic regimen
    Per ADA 2026 (metformin + GLP-1 / SGLT2 / insulin per phenotype) • varied • titrated
    trigger: A1c >8%
    Target <8% for healing; <7% if safe

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Open ulcer / wound on foot in patient with diabetes (IWGDF 2023); Foot redness / warmth / swelling — suspected infection (IDSA 2012 Lipsky); New foot pain or loss of sensation — neuropathy or ischemia (IWGDF 2023).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Diabetes-related foot disease (ulcer, infection, osteomyelitis)** (endo.diabetes-related-foot-disease.v1).
Phenotype framing: Phenotype: neuropathic ulcer, ischemic ulcer, neuro-ischemic, Charcot foot, gas-forming infection, necrotizing fasciitis, abscess, osteomyelitis, gangrene
Scope: Assess for ulcer (with/without infection), Charcot, ischemia, neuropathy; establish chronic foot risk class (IWGDF 0–3)

No severity triggers fired against current inputs.

Plan

Regimen axis: **IDSA / IWGDF 2023 — severity-tiered empirical antibiotic regimen for diabetic foot infection** — step "Tier 1 — Mild infection (superficial, no systemic signs, ≤2 cm cellulitis, no significant ischemia)".
1. cephalexin 500 mg PO QID PO q6h × 7–14 days (cephalosporin_1st_gen, first line) — IDSA 2023 — first-line MSSA/strep coverage
2. dicloxacillin 500 mg PO QID PO q6h × 7–14 days (penicillin_anti_staph, first line) — IDSA — alternative anti-staph penicillin
3. clindamycin 300–450 mg PO QID PO q6h × 7–14 days (lincosamide, second line) — PCN-allergic; check local D-test for inducible MRSA resistance
4. doxycycline 100 mg PO BID PO q12h × 7–14 days (tetracycline, second line) — IDSA — covers CA-MRSA + good tissue penetration
5. trimethoprim-sulfamethoxazole 1 DS tab (160/800) PO BID PO q12h × 7–14 days (folate_inhibitor, second line) — IDSA — covers CA-MRSA; renal dose; SJS warning + warfarin/sulfonylurea interactions

Setting playbook (outpatient) — Heal ulcers, prevent infection / amputation, optimize vascular and glycemic substrate, structured multidisciplinary follow-up (IWGDF 2023; ADA 2026)
6. cephalexin OR dicloxacillin OR clindamycin / doxycycline / TMP-SMX Per IDSA mild PO 7–14 days — IDSA mild infection (IDSA 2023 first-line + alternatives)
7. amoxicillin-clavulanate OR cipro+metro Per IDSA moderate PO 14–28 days — IDSA moderate (Broader Gram-negative + anaerobic)
8. aspirin 81 mg + statin ASA 81 mg + atorvastatin 40–80 mg PO daily — ASCVD/PAD (Secondary prevention)
9. optimized glycemic regimen Per ADA 2026 (metformin + GLP-1 / SGLT2 / insulin per phenotype) varied titrated — A1c >8% (Target <8% for healing; <7% if safe)

Non-pharmacologic actions:
- Total contact cast (TCC) for plantar neuropathic ulcer (gold standard offloading) (IWGDF 2023)
- Removable cast walker (RCW) if TCC contraindicated (IWGDF 2023)
- Sharp debridement at each visit (q1-2 wk) (IWGDF 2023)
- Wound dressings (foam, hydrogel, alginate per phase) (IWGDF 2023)
- Negative-pressure wound therapy (NPWT) for selected wounds (IWGDF 2023)
- Patient education: daily foot inspection, signs of infection, footwear, hygiene (IWGDF 2023; ADA 2026)
- Smoking cessation pharmacotherapy + counselling (ADA 2026)
- Multidisciplinary team: podiatry + wound care + endocrinology + vascular (IWGDF 2023; NICE 2019)
- Vaccinations review (Tdap, flu, pneumococcal, COVID, RSV) (ADA 2026)

AVOID / contraindication checks:
- Fluoroquinolone_tendon_aortic_qt_warnings (IDSA 2012 Lipsky)
- Rifampin_never_monotherapy_osteo (IDSA 2012 Lipsky)
- Linezolid_serotonergic_interactions_cytopenia_after_2_to_4_weeks (IDSA 2012 Lipsky)
- Vanco_AUC_targeted_renal_dose (IDSA 2012 Lipsky)
- Metformin_hold_if_AKI_or_contrast (ADA 2026)
- No_NSAIDs_in_AKI_or_active_infection_with_renal_concern (IWGDF 2023)
- TMP_SMX_warfarin_sulfonylurea_potentiation_and_hyperK (IDSA 2012 Lipsky)
- Tetanus_status_review (IWGDF 2023)

Monitoring

Regimen monitoring:
- wound size and depth weekly (IWGDF 2023)
- CRP and ESR q1 to 2 weeks during osteo therapy (IDSA 2012 Lipsky)
- A1c at 3 months target under 8 for healing (ADA 2026)
- BMP for renal function during aminoglycoside or vanco (IDSA 2012 Lipsky)
- vanco trough or AUC targeted 400 to 600 (IDSA 2012 Lipsky)
- rifampin LFT baseline and periodic (IDSA 2012 Lipsky)
- linezolid CBC weekly after 2 weeks (IDSA 2012 Lipsky)
- BG q4 to 6h during acute infection (ADA 2026)
- foot inspection daily during admission (IWGDF 2023)

Setting (outpatient) monitoring:
- Wound size + depth weekly (IWGDF 2023)
- CRP, ESR every 1-2 wk during infection (IDSA 2012 Lipsky)
- A1c at 3 months (ADA 2026)
- ABI/TBI/TcPO2 at baseline + as clinically indicated (IWGDF 2023)
- Offloading adherence audit (IWGDF 2023)

Follow-up plan: Multidisciplinary clinic q1–4 wk; podiatry + wound care + endocrinology + vascular; preventive education (daily inspection, footwear, hygiene); annual screening (monofilament, ABI/TBI, foot exam); secondary prevention after healed ulcer
- Close-out criterion: long-term care plan documented

Monitoring phase: Wound size + depth weekly; CRP/ESR every 1–2 wk during osteo treatment (expect ≥50% reduction by 4 wk); A1c at follow-up; weight-bearing audit; offloading adherence

Disposition

Current setting: outpatient — Heal ulcers, prevent infection / amputation, optimize vascular and glycemic substrate, structured multidisciplinary follow-up (IWGDF 2023; ADA 2026)

Disposition criteria:
- Continue outpatient if mild / moderate without systemic signs and reliable adherence (IDSA 2012 Lipsky)

Escalation triggers (move to higher acuity):
- Worsening size / depth / cellulitis → escalate IDSA tier or admit (IDSA 2012 Lipsky)
- Systemic signs / sepsis → admit (IDSA 2012 Lipsky)
- Non-healing despite optimal medical care → vascular consult for revascularization (IWGDF 2023)
- Suspected osteomyelitis → MRI + bone biopsy (IDSA 2012 Lipsky; IWGDF 2023)
- Charcot foot acute → immobilize and refer (IWGDF 2023)

Patient Action Plan

**Diabetic foot care home action plan**
Personalised values: ulcer_location, offloading_device, wound_care_team_contact, antibiotic_course, glycemic_targets.

**Stable — wound healing, no signs of infection** (green):
Triggers:
- Wound size shrinking each week
- No new redness, warmth, swelling, or pus
- No fever
- Glucose at target
- Footwear / offloading device worn as instructed
Actions:
- Inspect both feet daily (use mirror for plantar surface)
- Wear prescribed offloading device for ALL weight-bearing
- Wash + dry feet daily (especially between toes)
- Apply moisturizer to dry skin BUT NOT between toes
- Cut nails straight across; never trim corns/calluses at home
- Continue all prescribed medications
- Attend every follow-up visit
- Glucose monitoring per plan

**Caution — early changes, contact wound team** (yellow):
Triggers:
- New redness, warmth, or swelling around wound
- Wound is larger or deeper
- New drainage or cloudy fluid
- Mild new pain at wound or surrounding area
- Glucose persistently elevated
- Cannot wear offloading device for any reason
Actions:
- Call wound care team / podiatry same day
- Continue offloading
- Check glucose more frequently
- Take photo of wound for clinic visit
Contact provider when:
- Any new redness or change in wound appearance
- Glucose >250 repeatedly
- Cannot adhere to offloading

**Medical alert — go to ED now** (red):
Triggers:
- Fever ≥101°F (38.3°C)
- Spreading redness up the foot or leg
- Foul odour from wound or new discharge
- Gas / crepitus / black tissue / new gangrene
- Severe pain disproportionate to wound
- Unable to keep weight off foot
- Confusion, lightheadedness, or other systemic illness
- Sudden cold / pale / blue foot (acute limb ischemia)
Actions:
- Go to ED immediately
- Bring medication list and most recent wound photos / records
- Notify your wound care team
Contact provider when:
- Any red-zone symptom — go to ED, do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Systemic signs of infection (fever, hypotension, tachycardia, AMS, leukocytosis) in DFI (IDSA 2012 Lipsky)
- [LIFE_THREATENING] Crepitus, gas in tissue, rapidly spreading erythema, severe pain out of proportion (IDSA 2012 Lipsky)
- [SEVERE] Probe-to-bone positive AND MRI / bone biopsy confirms osteomyelitis (IDSA 2012 Lipsky; IWGDF 2023)

Citations

- IDSA / IWGDF 2023 — Diagnosis and treatment of diabetes-related foot infection + IWGDF 2023 prevention/management practical guidelines + ADA Standards of Care 2026 + SVS / ESVS / SCAI 2024 (CLTI) + WOCN 2022 [PMID:37779457](https://pubmed.ncbi.nlm.nih.gov/37779457/)
- Cited evidence (PMID 37779323) [PMID:37779323](https://pubmed.ncbi.nlm.nih.gov/37779323/)

Last reconciled with current guidelines: 2026-05-22.
References
  • IDSA / IWGDF 2023 — Diagnosis and treatment of diabetes-related foot infection + IWGDF 2023 prevention/management practical guidelines + ADA Standards of Care 2026 + SVS / ESVS / SCAI 2024 (CLTI) + WOCN 2022 — PMID:37779457
  • Cited evidence (PMID 37779323) — PMID:37779323