Antimicrobial management of complex biofilms in diabetic foot ulcers: a microbiological perspective

Diabetic foot ulcers (DFUs) are a significant health concern, often complicated by biofilm formation which delays healing and increases the risk of diabetic foot infections (DFIs). Effective management of complex biofilms is crucial for improving patient outcomes and reducing the risk of amputation and premature death. This review summarizes the current state of microbiological research on DFIs, focusing on bacterial populations, biofilm interactions, and their role in antibiotic resistance development, being based on a PubMed search from 1975 to 2025. It also explores recent advances in antimicrobial therapies, including phage therapy, antimicrobial peptides, and other novel treatments. Antimicrobial stewardship, broader access to medical resources, and improved sanitation are essential to diminish the impact of diabetes on healthcare systems. Furthermore, the development of a rapid tool to detect antibiotic-tolerant cells is fundamental to avoid DFIs relapse. The biofilms dynamics and the dual relationship between biofilms and the immune system should be further understood. While traditional antibiotics are essential to treat DFIs, a multi-combinatorial strategy combining conventional compounds with alternative therapies should be more effective to overcome resistance and promote wound healing in DFUs.