Consensus document
Consensus document on actions to prevent and to improve the management of diabetic foot in SpainDocumento de consenso sobre acciones de mejora en la prevención y manejo del pie diabético en España

https://doi.org/10.1016/j.endien.2020.08.016Get rights and content

Introduction

Diabetic foot disease is a serious complication of diabetes mellitus (DM), affecting 3-4% of people with DM around the world.1 The lifetime prevalence of suffering from a foot ulcer among people with DM is in the range 19-34%.2

Some 70% of diabetic foot ulcers (DFUs) remain open 20 weeks after treatment,3 and their prognosis is seriously affected by the presence of ischaemia or infection. Over 50% of patients with DFU have peripheral arterial disease,4 especially in middle- and high-income countries. Nearly 60% of DFUs become infected and this is the main cause of amputation.5

In Spain, the incidence rate of major amputations per 100,000 people/year was 0.48 between 2001 and 2015, although this figure varied significantly between the different autonomous regions.6 The five-year risk of death for a patient with a diabetic foot ulcer is two to five times greater than for a patient with no ulcer, and up to 70% of patients may die within five years after a major amputation.7 The hospital mortality rate associated with major amputation in Spain is 10%.6

Success in the prevention and treatment of diabetic foot disease depends on a well-organised multidisciplinary team using a holistic approach, in which the ulcer is seen as a sign of multi-organ disease. The effective organisation of this care requires systems and guidelines for education, detection, risk reduction, treatment and auditing. Comprehensive patient care, which includes follow-up and continuity of care, both in primary care and in specialised diabetic foot units, is key in the effective management of these patients.8

Section snippets

Development of the consensus statement

New guidelines on the management and prevention of diabetic foot, put together by the International Working Group on the Diabetic Foot (IWGDF), were launched in The Hague in May 2019.8 The organisation responsible for the implementation of the guidelines at an international level is D-FOOT International, which aims, through various projects such as AB(b)A (Auditing, Benchmarking and Accreditation: in Search of Excellence), to carry out specific actions in different countries to facilitate

Chapter 1. Risk classification and preventive actions8

The primary care team (doctor and nurse) will be responsible for performing vascular and neuropathic screening in order to assess the degree of risk of developing a diabetic foot ulcer.

If the patient is being treated by other specialists, the endocrinologist, nursing home doctor and/or internal medicine physician must ensure that these interventions are carried out.

  • Take a thorough medical history in order to analyse cardiovascular risk, chronic complications of diabetes and other comorbidities

Chapter 2. Diagnosis, referral and management of peripheral arterial disease (PAD)9

  • Examine distal pulses (posterior tibial and pedal) to rule out PAD in all diabetic patients with ulcers. If no pulses are found, they should be referred to a specialised angiology and vascular surgery unit/service.

  • In diabetic patients with an ulcer, in addition to ischaemia, assess the characteristics of the ulcer and the degree of infection (WIfI [Wound, Ischemia and foot Infection] Classification) in order to stratify the risk of amputation and the benefits of revascularisation.

Chapter 3. Diagnosis, referral and management of infection5

  • Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America (IDSA)/International Working Group on the Diabetic Foot (IWGDF) and SEACV classification systems.

  • Rule out osteomyelitis associated with diabetic foot ulcer using the probe-to-bone test and, if possible, plain X-ray.

  • Consider requesting an advanced imaging study (particularly magnetic resonance imaging) if the diagnosis of osteomyelitis remains uncertain.

  • Consider microbiological culture of bone

Chapter 4. Approach for patients with diabetic foot ulcer10

Considerations prior to managing patients with lesions:

If your centre/unit is going to treat diabetic foot lesions, the following will be necessary:

  • Identify your referral unit for appropriate referral of patients with complicated lesions.

  • Have staff suitably trained in specific skills:

  • Vascular examination: palpation of distal pulses of the foot (posterior tibial and pedal).

  • Assessment of infection.

  • Examination of ulcer/assessment of bone exposure: probe-to-bone test.

  • Surgical debridement.

Conflicts of interest

The authors declare that they have no conflicts of interest.

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Please cite this article as: Lázaro Martínez JL, Almaraz MC, Álvarez Hermida Á, Blanes Mompó I, Escudero Rodríguez JR, García Morales EA, et al. Documento de consenso sobre acciones de mejora en la prevención y manejo del pie diabético en España. Endocrinol Diabetes Nutr. 2021;68:509–513.

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