Consensus document for the diagnosis of peripheral bone infection in adults: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement)

Abstract

Introduction In adults with a suspicion of peripheral bone infection, evidence-based guidelines in choosing the most accurate diagnostic strategy are lacking. Aim and methods To provide an evidence-based, multidisciplinary consensus document on the diagnostic management of adult patients with PBIs, we performed a systematic review of relevant infectious, microbiological, orthopedic, radiological, and nuclear medicine literature. Delegates from four European societies (European Bone and Joint Infection Society, European Society of Microbiology and Infectious Diseases, European Society or Radiology, and European Association of Nuclear Medicine) defined clinical questions to be addressed, thoroughly reviewed the literature pertinent to each of the questions, and thereby evaluated the diagnostic accuracy of each diagnostic technique. Inclusion of the papers per statement was based on a PICO (Population/problem – Intervention/indicator – Comparator – Outcome) question following the strategy reported by the Oxford Centre for Evidence-based Medicine. For each statement, the level of evidence was graded according to the 2011 review of the Oxford Centre for Evidence-based Medicine. All approved statements were addressed taking into consideration the available diagnostic procedures, patient acceptance, tolerability, complications, and costs in Europe. Finally, a commonly agreed-upon diagnostic flowchart was developed. Electronic supplementary material The online version of this article (10.1007/s00259-019-4262-x) contains supplementary material, which is available to authorized users.

The accuracy of diagnostic Imaging techniques in patients with a suspected Fracture-related Infection (IFI) trial: study protocol for a prospective multicenter cohort study.

“…At this moment, no prospective sufficiently powered study has been published on the diagnostic accuracy of medical imaging modalities for FRI 9 10. The European Association of Nuclear Medicine (EANM), endorsed by the European Bone and Joint Infection Society (EBJIS), developed guidelines in which the WBC scintigraphy with SPECT/CT is regarded to be the most accurate advanced imaging technique for peripheral bone infection in patients with recent fractures or hardware in situ 12. However, this recommendation is based on scarce evidence in the literature and diagnostic studies specifically focussing on FRI are limited and report conflicting outcomes 10 13.…”

Diagnosing fracture-related infections: can we optimize our nuclear imaging techniques?

“…There are several types of imaging modalitiesy that may be preferred and the choice often depends on local expertise, costs and availability. The most commonly used techniques (singly or in combination) are plain radiography, computed tomography (CT), magnetic resonance imaging (MRI), three-phase bone scintigraphy (TPBS), white blood cell (WBC) or antigranulocyte antibody scintigraphy with single photon emission computed tomography (SPECT/CT) and 18 F-fluorodeoxyglucose positron emission tomography combined with low-dose or contrast-enhanced CT (FDG PET/CT) [1][2][3]. It is acknowledged in the literature that the optimal diagnostic strategy for FRI remains unclear [3][4][5].…”

“…The most commonly used techniques (singly or in combination) are plain radiography, computed tomography (CT), magnetic resonance imaging (MRI), three-phase bone scintigraphy (TPBS), white blood cell (WBC) or antigranulocyte antibody scintigraphy with single photon emission computed tomography (SPECT/CT) and 18 F-fluorodeoxyglucose positron emission tomography combined with low-dose or contrast-enhanced CT (FDG PET/CT) [1][2][3]. It is acknowledged in the literature that the optimal diagnostic strategy for FRI remains unclear [3][4][5]. A survey on preferred diagnostic imaging strategies conducted amongst 346 medical specialists (trauma surgeons, orthopaedic surgeons, nuclear medicine physicians and radiologists found a significant difference among the specialists and poor availability of local protocols to diagnose and treat FRI [5].…”

“…Recently, a consensus document from four European societies, including the EANM, the European Society of Radiology (ESR), the European Bone and Joint Infection Society (EBJIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), was published. It provides levels of evidence for each diagnostic modality and a commonly agreed diagnostic flow chart [3]. However, the available evidence was considered to be limited, and large multicentre prospective studies comparing the different imaging modalities are needed.…”

“…Focusing on the nuclear imaging modalities, TPBS plays a limited role and can only be used as a first screening method to exclude the presence of FRI in patients with a low probability of infection [3]. WBC scintigraphy and FDG PET provide higher accuracy for diagnosing FRI.…”