Guidelines on the classification of diabetic foot ulcers (IWGDF 2019)

Abstract

The International Working Group on the Diabetic Foot (IWGDF) has been publishing evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This publication represents a new guideline addressing the use of classifications of diabetic foot ulcers in routine clinical practice and reviews those which have been published. We only consider systems of classification used for active diabetic foot ulcers and do not include those that might be used to define risk of future ulceration. The guidelines are based on a review of the available literature and on expert opinion leading to the identification of eight key factors judged to contribute most to clinical outcomes. Classifications are graded on the number of key factors included as well as on internal and external validation and the use for which a classification is intended. Key factors judged to contribute to the scoring of classifications are of three types: patient related (end‐stage renal failure), limb‐related (peripheral artery disease and loss of protective sensation), and ulcer‐related (area, depth, site, single, or multiple and infection). Particular systems considered for each of the following five clinical situations: (a) communication among health professionals, (b) predicting the outcome of an individual ulcer, (c) as an aid to clinical decision‐making for an individual case, (d) assessment of a wound, with/without infection, and peripheral artery disease (assessment of perfusion and potential benefit from revascularisation), and (d) audit of outcome in local, regional, or national populations. We recommend: (a) for communication among health professionals the use of the SINBAD system (that includes Site, Ischaemia, Neuropathy, Bacterial Infection and Depth); (b) no existing classification for predicting outcome of an individual ulcer; (c) the Infectious Diseases Society of America/IWGDF (IDSA/IWGDF) classification for assessment of infection; (d) the WIfI (Wound, Ischemia, and foot Infection) system for the assessment of perfusion and the likely benefit of revascularisation; and (e) the SINBAD classification for the audit of outcome of populations.

Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update)

“…Assess the severity of infection using the IWGDF/ISDA classification criteria, 4,6 and in patients with PAD, we recommend using the WIfI (wound/ischaemia/infection) system to stratify amputation risk and revascularisation benefit. 3,6 For communication among health care professionals, we recommend the SINBAD system, which can also be used for audit of outcome of populations. 6 7 | ULCER TREATMENT Foot ulcers will heal in the majority of patients if the clinician bases treatment on the principles outlined below.…”

“…3,6 For communication among health care professionals, we recommend the SINBAD system, which can also be used for audit of outcome of populations. 6 7 | ULCER TREATMENT Foot ulcers will heal in the majority of patients if the clinician bases treatment on the principles outlined below. However, even optimum wound care cannot compensate for continuing trauma to the wound bed, or for inadequately treated ischemia or infection.…”

“…The Practical Guidelines are based on the IWGDF Guidelines 2019, consisting of evidence-based guideline chapters on • Classification of diabetic foot ulcers 6 The authors, as members of the editorial board of the IWGDF, have summarized the information from these six chapters and also provide additional advice based on expert opinion in selected areas for which the guideline chapters were not able to provide evidencebased recommendations. We refer the reader for details and background to the six evidence-based guideline chapters [1][2][3][4][5][6] and our development and methodology document 7 ; should this summary text appear to differ from information of these chapters, we suggest the reader defer to the specific guideline chapters. [1][2][3][4][5][6] Because terminology in this multidisciplinary area can sometimes be unclear, we have developed a separate IWGDF Definitions and Criteria document.…”

“…We refer the reader for details and background to the six evidence-based guideline chapters [1][2][3][4][5][6] and our development and methodology document 7 ; should this summary text appear to differ from information of these chapters, we suggest the reader defer to the specific guideline chapters. [1][2][3][4][5][6] Because terminology in this multidisciplinary area can sometimes be unclear, we have developed a separate IWGDF Definitions and Criteria document. 8 The information in these practical guidelines is aimed at the global community of health care professionals involved in the care of persons with diabetes.…”

Definitions and criteria for diabetic foot disease

“…In this paper, we provide an update of all definitions and criteria for diabetic foot disease based on the systematic reviews of the literature that form the basis of the 2019 IWGDF Guidelines. [3][4][5][6][7][8][9] Where possible, we have retained the definitions from previous versions 1 to facilitate consistent comparison with older studies. We have only made changes when the evidence necessitated updates of older definitions.…”