{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,26]],"date-time":"2026-10-26T21:25:34Z","timestamp":1793049934070,"version":"4.5.0"},"reference-count":32,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T00:00:00Z","timestamp":1774569600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>This study aimed to evaluate the IWGDF\/IDSA classification for prognostic stratification in diabetic foot infections (DFIs) and to develop and validate a clinical prediction model for individualized risk assessment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this retrospective study of 300 patients with DFIs (2020\u20132024), infection severity was graded as Grade 2 (mild), 3 (moderate), 3(O) (moderate with osteomyelitis), or 4 (severe). We analyzed baseline characteristics, microbiological profiles, treatment responses, and performed time-to-event analyses for ulcer healing and limb salvage. A nomogram predicting 6-month non-healing risk was developed using Cox regression, with performance assessed by C-index and calibration. Subgroup and sensitivity analyses (including competing-risk models) were conducted to test robustness.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Higher infection grades correlated with worse glycemic control (HbA1c: 9.8% in Grade 4 vs. 8.1% in Grade 2), higher peripheral arterial disease (PAD) prevalence (64.3% vs. 22.4%), and a pathogen shift from Gram-positive cocci (87.2% in Grade 2) to Gram-negative bacilli (\n                      <jats:italic>Pseudomonas aeruginosa<\/jats:italic>\n                      52.2%) and polymicrobial infections (60.9%) in Grade 4 (all\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001). Kaplan\u2013Meier analysis revealed a severity-dependent gradient in outcomes: median healing time prolonged from 6.0\u202fweeks (Grade 2) to 18.0\u202fweeks (Grade 4), while the 24-week cumulative amputation rate escalated to 66.7% in Grade 4. Osteomyelitis (Grade 3(O)) constituted a distinct high-risk subgroup, with outcomes approximating Grade 4. A nomogram incorporating infection grade, PAD, HbA1c\u202f\u2265\u202f9%, and revascularization status demonstrated good discrimination (C-index 0.82, bootstrap-corrected 0.80) and calibration (Hosmer\u2013Lemeshow\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.342), maintained in temporal validation (C-index 0.79). Subgroup analysis confirmed a significant interaction between infection grade and revascularization, with the greatest benefit in severe PAD patients (interaction\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.03). Sensitivity analyses, including competing-risk models, affirmed the robustness of the severity\u2013outcome association.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The IWGDF\/IDSA classification effectively stratifies DFI patients by integrated metabolic, vascular, microbiological, and prognostic risk. Osteomyelitis warrants distinct management. The developed nomogram provides a validated tool for individualized risk prediction, facilitating early targeted intervention. These findings advocate for a severity-guided, multidisciplinary treatment paradigm to improve outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1809285","type":"journal-article","created":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T05:19:45Z","timestamp":1774588785000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["Staged management of infected diabetic foot ulcers: a 300-patient cohort study on prognostic grading, pathogen dynamics, and individualized risk prediction"],"prefix":"10.3389","volume":"13","author":[{"given":"Yuce","family":"Zhang","sequence":"first","affiliation":[{"name":"The Fourth Hospital of Harbin Medical University","place":["Harbin, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jun","family":"Zhang","sequence":"additional","affiliation":[{"name":"The Fourth Hospital of Harbin Medical University","place":["Harbin, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,3,27]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"2314","DOI":"10.1001\/jama.2023.17291","article-title":"What are diabetic foot ulcers?","volume":"330","author":"Voelker","year":"2023","journal-title":"JAMA"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"1480","DOI":"10.47391\/JPMA.6634","article-title":"Diabetic foot ulcers: contemporary assessment and management","volume":"73","author":"Rehman","year":"2023","journal-title":"J Pak Med Assoc"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1001\/jama.2023.10578","article-title":"Diabetic foot ulcers: a review","volume":"330","author":"Armstrong","year":"2023","journal-title":"JAMA"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"655","DOI":"10.1016\/j.fcl.2022.02.004","article-title":"Limb salvage in severe diabetic foot infection","volume":"27","author":"Wukich","year":"2022","journal-title":"Foot Ankle Clin"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"e0014323","DOI":"10.1128\/cmr.00143-23","article-title":"Anaerobes in diabetic foot infections: pathophysiology, epidemiology, virulence, and management","volume":"37","author":"Villa","year":"2024","journal-title":"Clin Microbiol Rev"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"552","DOI":"10.3390\/ijms222111552","article-title":"Pathophysiology and molecular imaging of diabetic foot infections","volume":"22","author":"Rubitschung","year":"2021","journal-title":"Int J Mol Sci"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"e70123","DOI":"10.1111\/iwj.70123","article-title":"Re-infection after treatment for moderate and severe diabetic foot infections","volume":"21","author":"Lavery","year":"2024","journal-title":"Int Wound 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classification of foot ulcers in people with diabetes (IWGDF 2023 update)","volume":"40","author":"Monteiro-Soares","year":"2024","journal-title":"Diabetes Metab Res Rev"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"e002150","DOI":"10.1136\/bmjdrc-2021-002150","article-title":"Development and validation of a clinical prediction rule for development of diabetic foot ulceration: an analysis of data from five cohort studies","volume":"9","author":"Chappell","year":"2021","journal-title":"BMJ Open Diabetes Res Care"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"678771","DOI":"10.3389\/fimmu.2021.678771","article-title":"A bittersweet response to infection in diabetes; targeting neutrophils to modify inflammation and improve host immunity","volume":"12","author":"Dowey","year":"2021","journal-title":"Front Immunol"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"685","DOI":"10.3390\/antibiotics12040685","article-title":"Timing of revascularization and parenteral antibiotic treatment associated with therapeutic failures in ischemic diabetic foot infections","volume":"12","author":"Altmann","year":"2023","journal-title":"Antibiotics"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"e3644","DOI":"10.1002\/dmrr.3644","article-title":"Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update)","volume":"40","author":"Chen","year":"2024","journal-title":"Diabetes Metab Res Rev"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"316","DOI":"10.3390\/antibiotics12020316","article-title":"Influence of skin commensals on therapeutic outcomes of surgically debrided diabetic foot infections-a large retrospective comparative study","volume":"12","author":"U\u00e7kay","year":"2023","journal-title":"Antibiotics"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"e00059","DOI":"10.1002\/edm2.59","article-title":"Stopping antibiotics after surgical amputation in diabetic 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