348 © 2006 Diabetes UK. Diabetic Medicine, 23, 348– 359 DOI: 10.1111/j.1464-5491.2006.01785.x Introduction The impact of foot ulcers in diabetes Around 6% of people with diabetes in the UK have had foot ulceration [1]. The annual UK cost was estimated at £17m in 1994 [2]. Foot ulceration in diabetes has been associated with higher mortality [3] and reduced quality of life [4 – 6]. Infection and foot ulceration in diabetes People with diabetes are particularly susceptible to foot infection [7,8]. Infection in foot ulcers may be polymicrobial [9,10] and both the number of bacterial groups and bacterial density is thought to affect healing. High cell density can lead to alterations in colony behaviour through messaging and by their secreting a protective Correspondence to: Dr E. Andrea Nelson, School of Healthcare, University of Leeds, Baines Way, Leeds LS2 9UT, UK. E-mail: e.a.nelson@leeds.ac.uk 1 Members of the DASIDU Steering Group are listed at the end of the article. Abstract Background Foot ulcers in diabetes are associated with increased mortality, illness and reduced quality of life. Ulcer infection impairs healing and antimicro- bial interventions may cure infection, aid healing and reduce amputation rates. Objectives To systematically review the evidence for antimicrobial interven- tions for foot ulcers in diabetes. Methods We searched 16 databases, 11 Internet sites, three books, conference proceedings, a journal and bibliographies in November 2002. We included randomized controlled trials (RCTs) or controlled clinical trials (CCTs). Results Twenty-three studies investigated the effectiveness or cost-effectiveness of antimicrobial agents: intravenous antibiotics (n = 8); oral antibiotics (n = 5); topical antimicrobials (n = 4); subcutaneous granulocyte-colony stimulating factor (G-CSF) (n = 4); Ayurvedic preparations (n = 1): and sugar vs. antibiotics vs. standard care (n = 1). The trials were small and too dissimilar to be pooled. There is no strong evidence for any particular antimicrobial agent for the pre- vention of amputation, resolution of infection, or ulcer healing. Pexiganan cream may be as effective as oral ofloxacin for resolution of infection. Ampicil- lin and sulbactam cost less than imipenem/cilastatin, G-CSF cost less than stand- ard care and cadexomer iodine dressings may cost less than daily dressings. Conclusions The evidence is too weak to recommend any particular antimicro- bial agent. Large studies are needed of the effectiveness and cost-effectiveness of antimicrobial interventions. Diabet. Med. 23, 348–359 (2006) Keywords antimicrobials, diabetic foot ulcer, infection, systematic review Abbreviations CCTs, controlled clinical trials; G-CSF, granulocyte-colony stimu- lating factor; i.v., intravenously; kr., krona; N/A, not available; RCTs, rand- omized controlled trials Blackwell Publishing, Ltd. Oxford, UK DME Diabetic Medicine 0742-3071 Blackwell Publishing, 2005 22 Review Article Review article Systematic review of antimicrobial treatments for diabetic foot ulcers E. A. Nelson et al. Systematic review of antimicrobial treatments for diabetic foot ulcers E. A. Nelson*, S. O’Meara†, S. Golder‡, J. Dalton‡, D. Craig‡ and C. Iglesias†, on behalf of the DASIDU Steering Group 1 *School of Healthcare, University of Leeds, Leeds, †Department of Health Sciences and ‡Centre for Reviews and Dissemination, University of York, York, UK Accepted 30 May 2005 Final Acceptance 26 August 2005