# Local Versus Systemic Antibiotics for Diabetic Foot Infection—A Systematic Review and Meta‐Analysis

## TL;DR

This study reviews evidence on using local antibiotics for diabetic foot infections, suggesting combination therapy may improve outcomes but more research is needed.

## Contribution

The study provides a systematic review and meta-analysis comparing local, systemic, and combination antibiotic therapies for diabetic foot infections.

## Key findings

- Combination therapy showed higher clinical cure rates and faster healing times compared to systemic antibiotics alone.
- Local antibiotics alone did not show significant benefits across all outcomes.
- High-quality randomized trials are needed to confirm these findings and guide clinical practice.

## Abstract

Diabetic foot infection (DFI) includes soft tissue infection and osteomyelitis below the ankle and is a leading cause of lower limb amputation and mortality in diabetic patients. Treatment involves prolonged antibiotic therapy with surgical debridement or amputation. Local antimicrobial therapy offers an adjunct or alternative to systemic therapy. This systematic review and meta‐analysis assessed the efficacy of systemic antibiotic therapy compared with local and combination (local and systemic) therapy in DFI. A meta‐analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. A systematic search for studies was performed in eight sources (PROSPERO: CRD42024518421). The primary outcome was clinical cure rates, with secondary outcomes including clinical improvement, time to clinical cure, recurrence, amputation rates, and pathogen eradication. Twenty‐one studies with 2188 participants met the inclusion criteria, including 12 randomized controlled trials and 9 observational studies. Combination antibiotics were associated with increased clinical cure rates compared with systemic antibiotics alone (OR 2.08; 95% CI 1.30–3.35; p < 0.05) and faster healing times (Mean −9.8 days; 95% CI −15.1 to −4.4; p < 0.05); however, results failed to reach significance when looking at randomized studies alone. Results for local antibiotics alone were non‐significant for all outcomes. This meta‐analysis suggests that definitive conclusions about the use of local antibiotics in DFI are limited by bias and heterogeneity within included studies. Combined local and systemic antibiotic treatment may allow for direct tissue infiltration of antimicrobial therapy. However, high‐quality, blinded randomized controlled trials are required before routine clinical adoption.

Topical antibiotics are commonly used in local infections. There is limited guidance on their use in diabetic foot infection (DFI). This systematic review summarizes the existing evidence relating to local antibiotics in DFI in improving rates of clinical cure, clinical improvement, antimicrobial eradication, infection recurrence, and amputation rates in DFI, alone and in combination with systemic therapy. This study suggests the use of combination antibiotic therapy may improve cure rates and speed healing times in DFI. However, this review supports the need for further prospective, blinded, randomized studies before the routine use of local antibiotics can be routinely recommended.

Combined local and systemic antibiotic therapy improved clinical cure rates and shortened healing time in diabetic foot infections compared with systemic therapy alone. However, due to the low quality of existing studies, high‐quality randomized controlled trials are needed to confirm these findings.