For information about individual topics, including any decisions affecting this guideline, see the summary table of prioritisation board decisions. Start by checking that Apple Music is installed on your smartphone or iPad and that you have an active Apple Music subscription. Then simply gen z alphabet download and install the Apple Music Classical app on the same device and you’re all set. The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions. The recommendations aim to optimise antibiotic use and reduce antibiotic resistance.

But Apple Music will also offer the world’s largest classical audio catalogue along with hundreds of handpicked classical playlists. Classical music often involves multiple musicians recording works that have been recorded many times before and are referred to by different names. For example, from the formal Beethoven’s Piano Sonata No. 14 to the popular byname of Moonlight Sonata, or in multiple languages, such as Mondschein Sonata in German. Such complexities mean that classical music fans have been ill-served by streaming platforms.

NICE advice

Diabetes is a chronic condition and people may have had previous foot infections, with previous courses of antibiotics, that will influence their preferences. The committee retained the 2015 recommendation that samples should be taken for microbiological testing before, or as close as possible to, the start of antibiotic treatment. This would allow empirical antibiotic treatment to be changed if needed when results are available. All the risk assessment tools reviewed by the committee were able to predict ulcer occurrence with acceptable accuracy.

• We reviewed this guideline and will update the recommendations on treatment for diabetic foot ulcer in specific relation to considering topical oxygen therapy.
• Base antibiotic course length on the severity of the infection and a clinical assessment of response to treatment.
• Patient preference is also important, particularly for treatment that will involve a hospital stay or be prolonged.

Advice

The committee agreed that a shorter course was generally as effective as a longer course for adults with a mild diabetic foot infection, and a 7‑day course was sufficient for most people. However, it agreed that a longer course (up to a further 7 days) may be needed for some people based on a clinical assessment of their symptoms and history. They discussed the limited evidence on antibiotic course length, which compared 6 weeks with 12 weeks in adults with diabetic foot osteomyelitis.

Why the committee made the recommendation

Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. We use the best available evidence to develop recommendations that guide decisions in health, public health and social care. Patient preference is also important, particularly for treatment that will involve a hospital stay or be prolonged.

The committee agreed that in people with diabetes, all foot wounds are likely to be colonised with bacteria. However, for people with a diabetic foot infection, prompt treatment of the infection is important to prevent complications, including limb-threatening infections. The evidence showed that 95.5% of people assessed as low risk at their first clinical assessment remained in the low-risk group at their final assessment 8 years later.

• Based on evidence, their experience and resistance data, the committee agreed that flucloxacillin is an effective empirical antibiotic for mild diabetic foot infections (with dosing taking account of a person's body weight and renal function).
• PODUS had a higher c‑statistic than SIGN, but it did not report sensitivity or specificity.
• People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
• Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.
• When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service.
• No evidence was identified comparing antibiotic dose, frequency or route of administration.

It is also a chance to teach people how to look after their feet, and to emphasise the importance of doing so. Many people with diabetes do not have good foot care routines, or do not have foot care routines at all. And they may benefit from regular advice about risk factors for foot problems.

Assessing the risk of developing a diabetic foot problem

For a short explanation of why the committee did not change the recommendations that were reviewed in 2023, and how this might affect practice, see the rationale and impact section on managing the risk of developing a diabetic foot problem. No evidence was identified comparing antibiotic dose, frequency or route of administration. This guideline uses 'diabetic foot problem' throughout, because this is the term healthcare professionals will most commonly recognise for foot problems in people with diabetes. We do not mean to imply that people with diabetes should be blamed for their foot problems, and they should still be treated as individuals with their own needs, preferences and values. For a short explanation of why the committee made these 2019 recommendations and how they might affect practice, see the rationale and impact section on choice of antibiotic, dose frequency, route of administration and course length. The committee agreed that the choice of antibiotic in adults should be based on severity of infection (mild, moderate or severe) and the risk of complications, while minimising adverse effects and antibiotic resistance.

Diabetic foot problem

These sections briefly explain why the committee made the recommendations and how they might affect practice. Local infection with signs of systemic inflammatory response (such as temperature of more than 38°C or less than 36°C, increased heart rate or increased respiratory rate). Skin takes some time to return to normal, and full resolution of symptoms after a course of antibiotics is not expected. The treatment will depend on how severe the ulcer is, where it is, and what you would prefer.

Foot assessments are currently part of the annual diabetes review, so it makes sense to continue to include the foot check and risk assessment in that appointment. There are also Quality and Outcomes Framework (QOF) indicators for annual foot examination and risk classification, which further justify retaining the current system. Base antibiotic course length on the severity of the infection and a clinical assessment of response to treatment. Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics. We reviewed this guideline and will update the recommendations on treatment for diabetic foot ulcer in specific relation to considering topical oxygen therapy.

The committee agreed that for adults with a moderate or severe diabetic foot infection (which includes osteomyelitis), a 7‑day course would be a minimum, with antibiotic treatment for up to 6 weeks if they have osteomyelitis. When prolonged antibiotic treatment is given, oral options should be used and treatment should be reviewed regularly, taking into account the need for continued antibiotics. The committee discussed antibiotic choices for osteomyelitis and agreed that the empirical choices for moderate and severe diabetic foot infection are also effective empirical choices for osteomyelitis. For adults with a moderate or severe diabetic foot infection, a choice of antibiotics (or combinations of antibiotics) should be available. This enables selection based on individual patient factors, likely pathogens, and guided by microbiological results where available. In moderate and severe infection (which includes osteomyelitis), broader cover is needed because aerobic and anaerobic bacteria may be present.

There were no significant differences in classification accuracy (assessed using c‑statistics) between the different risk assessment tools. When considering classification accuracy, sensitivity and specificity together, the PODUS and SIGN systems were the best. PODUS had a higher c‑statistic than SIGN, but it did not report sensitivity or specificity. 'Diabetic foot problem' refers to any problem affecting the feet in people with diabetes that is caused by loss of sensation (peripheral sensory neuropathy) and/or circulation problems (peripheral arterial disease). These antibiotics may also be appropriate in other situations based on microbiological results and specialist advice. Other antibiotics may be appropriate based on microbiological results and specialist advice.

They recommended that if a diabetic foot infection is suspected or confirmed in children or young people, specialist advice should be sought regarding antibiotic choice and regimen. The committee agreed to retain the recommendation from the 2015 guideline that antibiotics should be started as soon as possible if a diabetic foot infection is suspected. The choice of antibiotic would depend on the severity of infection, although the committee acknowledged that the studies they looked at did not always differentiate between severities. The committee accepted the Infectious Diseases Society of America's definitions of mild, moderate and severe infection, and recommended that this should be taken into account when choosing an antibiotic.