IDSA GUIDELINES

2012 Infectious Diseases Society of America

Clinical Practice Guideline for the Diagnosis
and Treatment of Diabetic Foot Infectionsa
Benjamin A. Lipsky,1 Anthony R. Berendt,2 Paul B. Cornia,3 James C. Pile,4 Edgar J. G. Peters,5 David G. Armstrong,6

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H. Gunner Deery,7 John M. Embil,8 Warren S. Joseph,9 Adolf W. Karchmer,10 Michael S. Pinzur,11 and Eric Senneville12
1
Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle; 2Bone Infection Unit, Nuffield
Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford; 3Department of Medicine, University of Washington, Veteran Affairs Puget Sound
Health Care System, Seattle; 4Divisions of Hospital Medicine and Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio; 5Department of
Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands; 6Southern Arizona Limb Salvage Alliance, Department of Surgery,
University of Arizona, Tucson; 7Northern Michigan Infectious Diseases, Petoskey; 8Department of Medicine, University of Manitoba, Winnipeg,
Canada; 9Division of Podiatric Surgery, Department of Surgery, Roxborough Memorial Hospital, Philadelphia, Pennsylvania; 10Department of Medicine,
Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; 11Department of
Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois; and 12Department of Infectious Diseases, Dron Hospital,
Tourcoing, France

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs)
typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with
microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence.
Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more
extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification
system, along with a vascular assessment, helps determine which patients should be hospitalized, which may
require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs
are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common
causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic
or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.
Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected
wounds, obtain a post-debridement specimen ( preferably of tissue) for aerobic and anaerobic culture. Empiric
antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for
infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually
require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but
magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients
with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat
(often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require
some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds
must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic
foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive
measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organiz-
ations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Received 21 March 2012; accepted 22 March 2012. Correspondence: Benjamin A. Lipsky, MD, University of Washington, VA Puget
a
It is important to realize that guidelines cannot always account for individual Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108
variation among patients. They are not intended to supplant physician judgment ([email protected]).
with respect to particular patients or special clinical situations. IDSA considers Clinical Infectious Diseases 2012;54(12):1679–84
adherence to these guidelines to be voluntary, with the ultimate determination Published by Oxford University Press on behalf of the Infectious Diseases Society of
regarding their application to be made by the physician in the light of each America 2012.
patient’s individual circumstances. DOI: 10.1093/cid/cis460

IDSA Guideline for Diabetic Foot Infections • CID 2012:54 (15 June) • 1679
EXECUTIVE SUMMARY 2. Clinicians should be aware of factors that increase the
risk for DFI and especially consider infection when these
Diabetic foot infections (DFIs) are a frequent clinical problem. factors are present; these include a wound for which the
Properly managed, most can be cured, but many patients probe-to-bone (PTB) test is positive; an ulceration present for
needlessly undergo amputations because of improper diagnos- >30 days; a history of recurrent foot ulcers; a traumatic foot
tic and therapeutic approaches. Infection in foot wounds wound; the presence of peripheral vascular disease in the af-
should be defined clinically by the presence of inflammation fected limb; a previous lower extremity amputation; loss of
or purulence, and then classified by severity. This approach protective sensation; the presence of renal insufficiency; or a
helps clinicians make decisions about which patients to hospi- history of walking barefoot (strong, low).
talize or to send for imaging procedures or for whom to rec- 3. Clinicians should select and routinely use a validated
ommend surgical interventions. Many organisms, alone or in classification system, such as that developed by the International
combinations, can cause DFI, but gram-positive cocci (GPC), Working Group on the Diabetic Foot (IWGDF) (abbreviated
especially staphylococci, are the most common. with the acronym PEDIS) or IDSA (see below), to classify infec-

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Although clinically uninfected wounds do not require anti- tions and to help define the mix of types and severity of their
biotic therapy, infected wounds do. Empiric antibiotic regi- cases and their outcomes (strong, high). The DFI Wound Score
mens must be based on available clinical and epidemiologic may provide additional quantitative discrimination for research
data, but definitive therapy should be based on cultures of purposes (weak, low). Other validated diabetic foot classification
infected tissue. Imaging is especially helpful when seeking schemes have limited value for infection, as they describe only
evidence of underlying osteomyelitis, which is often difficult its presence or absence (moderate, low).
to diagnose and treat. Surgical interventions of various types
are often needed and proper wound care is important for
successful cure of the infection and healing of the wound. II. How should I assess a diabetic patient presenting with a foot
infection?
Patients with a DFI should be evaluated for an ischemic
Recommendations
foot, and employing multidisciplinary foot teams improves
4. Clinicians should evaluate a diabetic patient presenting
outcomes.
with a foot wound at 3 levels: the patient as a whole, the af-
Summarized below are the recommendations made in the
fected foot or limb, and the infected wound (strong, low).
new guidelines for diabetic foot infections. The expert panel
5. Clinicians should diagnose infection based on the pres-
followed a process used in the development of other Infectious
ence of at least 2 classic symptoms or signs of inflammation
Diseases Society of America (IDSA) guidelines, which in-
(erythema, warmth, tenderness, pain, or induration) or puru-
cluded a systematic weighting of the strength of recommen-
lent secretions. They should then document and classify the
dation and quality of evidence using the GRADE (Grading of
severity of the infection based on its extent and depth and the
Recommendations Assessment, Development and Evaluation)
presence of any systemic findings of infection (strong, low).
system [1–6] (Table 1). A detailed description of the methods,
6. We recommend assessing the affected limb and foot for
background, and evidence summaries that support each of the
arterial ischemia (strong, moderate), venous insufficiency,
recommendations can be found online in the full text of the
presence of protective sensation, and biomechanical problems
guidelines.
(strong, low).
7. Clinicians should debride any wound that has necrotic
RECOMMENDATIONS FOR MANAGING tissue or surrounding callus; the required procedure may
DIABETIC FOOT INFECTIONS range from minor to extensive (strong, low).

I. In which diabetic patients with a foot wound should I suspect

infection, and how should I classify it? III. When and from whom should I request a consultation for a
Recommendations patient with a diabetic foot infection?
1. Clinicians should consider the possibility of infection oc- Recommendations
curring in any foot wound in a patient with diabetes (strong, 8. For both outpatients and inpatients with a DFI, clini-
low). Evidence of infection generally includes classic signs of cians should attempt to provide a well-coordinated approach
inflammation (redness, warmth, swelling, tenderness, or pain) by those with expertise in a variety of specialties, preferably by
or purulent secretions, but may also include additional or sec- a multidisciplinary diabetic foot care team (strong, moderate).
ondary signs (eg, nonpurulent secretions, friable or discolored Where such a team is not yet available, the primary treating
granulation tissue, undermining of wound edges, foul odor) clinician should try to coordinate care among consulting
(strong, low). specialists.

1680 • CID 2012:54 (15 June) • Lipsky et al

Table 1. Strength of Recommendations and Quality of the Evidence

Strength of Clarity of Balance Between

Recommendation and Desirable and Undesirable Methodological Quality of Supporting
Quality of Evidence Effects Evidence (Examples) Implications
Strong recommendation, Desirable effects clearly Consistent evidence from Recommendation can apply to most
high-quality evidence outweigh undesirable well-performed RCTs or patients in most circumstances.
effects, or vice versa exceptionally strong evidence from Further research is unlikely to
unbiased observational studies change our confidence in the
estimate of effect
Strong recommendation, Desirable effects clearly Evidence from RCTs with important Recommendation can apply to most
moderate-quality outweigh undesirable limitations (inconsistent results, patients in most circumstances.
evidence effects, or vice versa methodological flaws, indirect, or Further research (if performed) is
imprecise) or exceptionally strong likely to have an important impact
evidence from unbiased on our confidence in the estimate
observational studies of effect and may change the

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estimate
Strong recommendation, Desirable effects clearly Evidence for at least 1 critical Recommendation may change when
low-quality evidence outweigh undesirable outcome from observational higher-quality evidence becomes
effects, or vice versa studies, RCTs with serious flaws available. Further research (if
or indirect evidence performed) is likely to have an
important impact on our
confidence in the estimate of
effect and is likely to change the
estimate
Strong recommendation, Desirable effects clearly Evidence for at least 1 critical Recommendation may change when
very low-quality outweigh undesirable outcome from unsystematic higher-quality evidence becomes
evidence (very rarely effects, or vice versa clinical observations or very available; any estimate of effect for
applicable) indirect evidence at least 1 critical outcome is very
uncertain
Weak recommendation, Desirable effects closely Consistent evidence from well- The best action may differ depending
high-quality evidence balanced with undesirable performed RCTs or exceptionally on circumstances or patients or
effects strong evidence from unbiased societal values. Further research is
observational studies unlikely to change our confidence
in the estimate of effect
Weak recommendation, Desirable effects closely Evidence from RCTs with important Alternative approaches likely to be
moderate-quality balanced with undesirable limitations (inconsistent results, better for some patients under
evidence effects methodological flaws, indirect, or some circumstances. Further
imprecise) or exceptionally strong research (if performed) is likely to
evidence from unbiased have an important impact on our
observational studies confidence in the estimate of
effect and may change the
estimate
Weak recommendation, Uncertainty in the estimates Evidence for at least 1 critical Other alternatives may be equally
low-quality evidence of desirable effects, harms, outcome from observational reasonable. Further research is
and burden; desirable studies, RCTs with serious flaws, very likely to have an important
effects, harms, and burden or indirect evidence impact on our confidence in the
may be closely balanced estimate of effect and is likely to
change the estimate
Weak recommendation, Major uncertainty in the Evidence for at least 1 critical Other alternatives may be equally
very low-quality estimates of desirable outcome from unsystematic reasonable. Any estimate of effect,
evidence effects, harms, and clinical observations or very for at least 1 critical outcome, is
burden; desirable effects indirect evidence very uncertain
may or may not be
balanced with undesirable
effects or may be closely
balanced

Abbreviation: RCT, randomized controlled trial.

9. Diabetic foot care teams can include (or should have 10. Clinicians without adequate training in wound debridement
ready access to) specialists in various fields; patients with a should seek consultation from those more qualified for this task,
DFI may especially benefit from consultation with an infec- especially when extensive procedures are required (strong, low).
tious disease or clinical microbiology specialist and a surgeon 11. If there is clinical or imaging evidence of significant
with experience and interest in managing DFIs (strong, low). ischemia in an infected limb, we recommend the clinician

IDSA Guideline for Diabetic Foot Infections • CID 2012:54 (15 June) • 1681
consult a vascular surgeon for consideration of revasculariza- VI. How should I initially select, and when should I modify, an
tion (strong, moderate). antibiotic regimen for a diabetic foot infection? (See question
12. We recommend that clinicians unfamiliar with pressure VIII for recommendations for antibiotic treatment of
off-loading or special dressing techniques consult foot or osteomyelitis)
wound care specialists when these are required (strong, low). Recommendations
13. Providers working in communities with inadequate 19. We recommend that clinically uninfected wounds not
access to consultation from specialists might consider devising be treated with antibiotic therapy (strong, low).
systems (eg, telemedicine) to ensure expert input on managing 20. We recommend prescribing antibiotic therapy
their patients (strong, low). for all infected wounds, but caution that this is often insuffi-
cient unless combined with appropriate wound care (strong,
low).
IV. Which patients with a diabetic foot infection should I 21. We recommend that clinicians select an empiric anti-
hospitalize, and what criteria should they meet before I biotic regimen on the basis of the severity of the infection and

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discharge them? the likely etiologic agent(s) (strong, low).
Recommendations a. For mild to moderate infections in patients who have
14. We recommend that all patients with a severe infection, not recently received antibiotic treatment, we suggest
selected patients with a moderate infection with complicating that therapy just targeting aerobic GPC is sufficient (weak,
features (eg, severe peripheral arterial disease [PAD] or lack of low).
home support), and any patient unable to comply with the b. For most severe infections, we recommend starting
required outpatient treatment regimen for psychological or broad-spectrum empiric antibiotic therapy, pending
social reasons be hospitalized initially. Patients who do not culture results and antibiotic susceptibility data (strong,
meet any of these criteria, but are failing to improve with out- low).
patient therapy, may also need to be hospitalized (strong, low). c. Empiric therapy directed at Pseudomonas aeruginosa
15. We recommend that prior to being discharged, a is usually unnecessary except for patients with risk
patient with a DFI should be clinically stable; have had any factors for true infection with this organism (strong,
urgently needed surgery performed; have achieved acceptable low).
glycemic control; be able to manage (on his/her own or with d. Consider providing empiric therapy directed against
help) at the designated discharge location; and have a well- methicillin-resistant Staphylococcus aureus (MRSA) in a
defined plan that includes an appropriate antibiotic regimen patient with a prior history of MRSA infection; when the
to which he/she will adhere, an off-loading scheme (if local prevalence of MRSA colonization or infection is
needed), specific wound care instructions, and appropriate high; or if the infection is clinically severe (weak, low).
outpatient follow-up (strong, low). 22. We recommend that definitive therapy be based on the
results of an appropriately obtained culture and sensitivity
testing of a wound specimen as well as the patient’s clinical
V. When and how should I obtain specimen(s) for culture from a response to the empiric regimen (strong, low).
patient with a diabetic foot wound? 23. We suggest basing the route of therapy largely on infec-
Recommendations tion severity. We prefer parenteral therapy for all severe, and
16. For clinically uninfected wounds, we recommend not some moderate, DFIs, at least initially (weak, low), with a
collecting a specimen for culture (strong, low). switch to oral agents when the patient is systemically well and
17. For infected wounds, we recommend that clinicians culture results are available. Clinicians can probably use highly
send appropriately obtained specimens for culture prior to bioavailable oral antibiotics alone in most mild, and in many
starting empiric antibiotic therapy, if possible. Cultures may moderate, infections and topical therapy for selected mild
be unnecessary for a mild infection in a patient who has not superficial infections (strong, moderate).
recently received antibiotic therapy (strong, low). 24. We suggest continuing antibiotic therapy until, but not
18. We recommend sending a specimen for culture that is beyond, resolution of findings of infection, but not through
from deep tissue, obtained by biopsy or curettage after the complete healing of the wound (weak, low). We suggest an
wound has been cleansed and debrided. We suggest avoiding initial antibiotic course for a soft tissue infection of about 1–2
swab specimens, especially of inadequately debrided wounds, weeks for mild infections and 2–3 weeks for moderate to
as they provide less accurate results (strong, moderate). severe infections (weak, low).

1682 • CID 2012:54 (15 June) • Lipsky et al

VII. When should I consider imaging studies to evaluate uncertainty, inadequate culture information, failure of
a diabetic foot infection, and which should I select? response to empiric treatment (weak, low).
Recommendations 35. Clinicians can consider using either primarily surgical or
25. We recommend that all patients presenting with a new primarily medical strategies for treating DFO in properly selected
DFI have plain radiographs of the affected foot to look for patients (weak, moderate). In noncomparative studies each ap-
bony abnormalities (deformity, destruction) as well as for proach has successfully arrested infection in most patients.
soft tissue gas and radio-opaque foreign bodies (strong, 36. When a radical resection leaves no remaining infected
moderate). tissue, we suggest prescribing antibiotic therapy for only a
26. We recommend using magnetic resonance imaging short duration (2–5 days) (weak, low). When there is persist-
(MRI) as the study of choice for patients who require further ent infected or necrotic bone, we suggest prolonged (≥4
(ie, more sensitive or specific) imaging, particularly when soft weeks) antibiotic treatment (weak, low).
tissue abscess is suspected or the diagnosis of osteomyelitis 37. For specifically treating DFO, we do not currently
remains uncertain (strong, moderate). support using adjunctive treatments such as hyperbaric

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27. When MRI is unavailable or contraindicated, clinicians oxygen therapy, growth factors (including granulocyte colony-
might consider the combination of a radionuclide bone scan stimulating factor), maggots (larvae), or topical negative
and a labeled white blood cell scan as the best alternative pressure therapy (eg, vacuum-assisted closure) (weak, low).
(weak, low).
IX. In which patients with a diabetic foot infection should
VIII. How should I diagnose and treat osteomyelitis of the foot in I consider surgical intervention, and what type of procedure
a patient with diabetes? may be appropriate?
Recommendations Recommendations
28. Clinicians should consider osteomyelitis as a potential 38. We suggest that nonsurgical clinicians consider request-
complication of any infected, deep, or large foot ulcer, ing an assessment by a surgeon for patients with a moderate
especially one that is chronic or overlies a bony prominence or severe DFI (weak, low).
(strong, moderate). 39. We recommend urgent surgical intervention for most
29. We suggest doing a PTB test for any DFI with an open foot infections accompanied by gas in the deeper tissues, an
wound. When properly conducted and interpreted, it can help abscess, or necrotizing fasciitis, and less urgent surgery for
to diagnose (when the likelihood is high) or exclude (when wounds with substantial nonviable tissue or extensive bone or
the likelihood is low) diabetic foot osteomyelitis (DFO) joint involvement (strong, low).
(strong, moderate). 40. We recommend involving a vascular surgeon early on
30. We suggest obtaining plain radiographs of the foot, but to consider revascularization whenever ischemia complicates a
they have relatively low sensitivity and specificity for confirm- DFI, but especially in any patient with a critically ischemic
ing or excluding osteomyelitis (weak, moderate). Clinicians limb (strong, moderate).
might consider using serial plain radiographs to diagnose or 41. Although most qualified surgeons can perform an ur-
monitor suspected DFO (weak, low). gently needed debridement or drainage, we recommend that in
31. For a diagnostic imaging test for DFO, we recommend DFI cases requiring more complex or reconstructive procedures,
using MRI (strong, moderate). However, MRI is not always the surgeon should have experience with these problems and
necessary for diagnosing or managing DFO (strong, low). adequate knowledge of the anatomy of the foot (strong, low).
32. If MRI is unavailable or contraindicated, clinicians
might consider a leukocyte or antigranulocyte scan, preferably X. What types of wound care techniques and dressings are
combined with a bone scan (weak, moderate). We do not rec- appropriate for diabetic foot wounds?
ommend any other type of nuclear medicine investigations Recommendations
(weak, moderate). 42. Diabetic patients with a foot wound should receive ap-
33. We suggest that the most definitive way to diagnose DFO propriate wound care, which usually consists of the following:
is by the combined findings on bone culture and histology a. Debridement, aimed at removing debris, eschar, and
(strong, moderate). When bone is debrided to treat osteomyelitis, surrounding callus (strong, moderate). Sharp (or surgi-
we suggest sending a sample for culture and histology (strong, cal) methods are generally best (strong, low), but mech-
low). anical, autolytic, or larval debridement techniques may
34. For patients not undergoing bone debridement, we be appropriate for some wounds (weak, low).
suggest that clinicians consider obtaining a diagnostic bone b. Redistribution of pressure off the wound to the entire
biopsy when faced with specific circumstances, eg, diagnostic weight-bearing surface of the foot (“off-loading”).

IDSA Guideline for Diabetic Foot Infections • CID 2012:54 (15 June) • 1683
 While particularly important for plantar wounds, this the IDSA requires full disclosure of all relationships, regardless of rele-
vancy to the guideline topic. The reader of these guidelines should be
is also necessary to relieve pressure caused by dres-
mindful of this when the list of disclosures is reviewed. B. L. has served as
sings, footwear, or ambulation to any surface of the a consultant to Merck, Pfizer, Cubist, Innocoll, TaiGen, KCI, and Dipex-
wound (strong, high). ium. E. S. has served on the board of and consulted for Novartis. H. G. D.
c. Selection of dressings that allow for moist wound has served on the speakers’ bureau for Merck and Sanofi. J. P. has served
as a consultant to Pfizer and Ortho McNeil. M. P. has served as a consult-
healing and control excess exudation. The choice of ant for Orthopedic Implants for Deputy Orthopedics and Small Bone
dressing should be based on the size, depth, and nature Innovation. W. J. has served as a consultant for Merck, Pfizer, Cerexa, and
of the ulcer (eg, dry, exudative, purulent) (strong, low). Dipexium and has served on the speakers’ bureaus of Merck and Pfizer. A.
W. K. is on the boards of Pfizer and Merck and the speakers’ bureau for
43. We do not advocate using topical antimicrobials for
Astella, and consults for Novartis. All other authors report no potential
treating most clinically uninfected wounds. conflicts.
44. No adjunctive therapy has been proven to improve res- All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
olution of infection, but for selected diabetic foot wounds that
content of the manuscript have been disclosed.
are slow to heal, clinicians might consider using bioengineered

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skin equivalents (weak, moderate), growth factors (weak, mod- References
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1684 • CID 2012:54 (15 June) • Lipsky et al