Integrating clinical data into evidence-based practice: institutional guideline development for diabetic foot infections

Background/objectives Diabetic foot infections (DFIs) are a major cause of morbidity in low- and middle-income countries such as Pakistan, where antimicrobial resistance (AMR) and the absence of localized guidelines complicate their management. This study aimed to analyze the microbiological profile of DFIs and develop evidence-based, context-specific empirical treatment recommendations. Methods We conducted a retrospective study at a tertiary care hospital in Pakistan, reviewing all diabetic foot related admissions between January 2022 and December 2023. Patients with clinically suspected infections had wound cultures taken and were classified by infection severity using IDSA/IWGDF criteria. Wound specimens from 400 DFI patients were subjected to culture and CLSI-standard antimicrobial susceptibility testing. Pathogen patterns were analyzed across severity groups. A multidisciplinary stewardship team used these findings, together with international guidelines, to develop severity-specific institutional-based empiric treatment recommendations. Results A total of 118 culture-positive samples from 400 admissions were analyzed. Gram-negative organisms predominated (62%), followed by Escherichia coli (25%), Proteus mirabilis (14%), and Pseudomonas aeruginosa (10%). Methicillin-resistant Staphylococcus aureus ( MRSA) accounted for 23% and methicillin-sensitive Staphylococcus aureus ( MSSA) 10%. E. coli was highly susceptible to tigecycline (86%) and amikacin (83%), while Proteus mirabilis was highly susceptible to carbapenems and piperacillin–tazobactam. MRSA/MSSA remain universally susceptible to vancomycin and linezolid. Based on these patterns, severity-stratified empiric regimens were recommended. Evidence grading supported strong recommendations for moderate to severe infections (SoR: Strong; QoE: Moderate). Conclusion This study highlights the limited role of Access antibiotics in DFIs, with Watch agents serving as the main empiric therapy and Reserve drugs reserved for multidrug-resistant cases. Using hospital antibiograms, international standards, and expert consensus, we developed a locally tailored institutional guideline for DFI management, which is expected to enhance patient care and antimicrobial stewardship, with periodic updates required as resistance evolves.