The Role of Serial Radiographs to Diagnose Diabetic Foot Bone Infection.

Leone, Antonio Maria; Bianco, Nicola Carlo; D’Ambra, Giulia; Lucchesi, Salvatore; Rosa, Elisa La; Infante, Amato; Perla, Daniele; Gullì, Consolato

doi:10.4084/mjhid.2022.055

Cited by 7 publications

(5 citation statements)

References 30 publications

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“…21 Radiographic imaging alone has a pooled sensitivity and specificity of 0.54 and 0.68. 22 Serial radiographs have improved sensitivity of 0.89 but decreased specificity of 0.38 23 as well as low PPV and NPV (0.87 and 0.43). 23 Probe to bone has some excellent diagnostic characteristics; however, it is not a test that is commonly performed by internists, hospitalists, physician assistants or other specialists.…”

Section: Discussionmentioning

confidence: 99%

“…22 Serial radiographs have improved sensitivity of 0.89 but decreased specificity of 0.38 23 as well as low PPV and NPV (0.87 and 0.43). 23 Probe to bone has some excellent diagnostic characteristics; however, it is not a test that is commonly performed by internists, hospitalists, physician assistants or other specialists. Perhaps by combining diagnostic studies, such as biomarkers and radiographs and clinical characteristic, we may be able to improve the diagnostic characteristics to identify osteomyelitis.…”

Section: Discussionmentioning

confidence: 99%

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Update of biomarkers to diagnose diabetic foot osteomyelitis: A meta‐analysis and systematic review

Ansert,

Tarricone,

Coye

et al. 2024

Wound Repair Regeneration

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The aim of this study was to evaluate the diagnostic characteristics of biomarker for diabetic foot osteomyelitis (DFO). We searched PubMed, Scopus, Embase and Medline for studies who report serological markers and DFO before December 2022. Studies must include at least one of the following diagnostic parameters for biomarkers: area under the curve, sensitivities, specificities, positive predictive value, negative predictive value. Two authors evaluated quality using the Quality Assessment of Diagnostic Accuracy Studies tool. We included 19 papers. In this systematic review, there were 2854 subjects with 2134 (74.8%) of those patients being included in the meta‐analysis. The most common biomarkers were erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP) and procalcitonin (PCT). A meta‐analysis was then performed where data were evaluated with Forrest plots and receiver operating characteristic curves. The pooled sensitivity and specificity were 0.72 and 0.75 for PCT, 0.72 and 0.76 for CRP and 0.70 and 0.77 for ESR. Pooled area under the curves for ESR, CRP and PCT were 0.83, 0.77 and 0.71, respectfully. Average diagnostic odds ratios were 16.1 (range 3.6–55.4), 14.3 (range 2.7–48.7) and 6.7 (range 3.6–10.4) for ESR, CRP and PCT, respectfully. None of the biomarkers we evaluated could be rated as ‘outstanding’ to diagnose osteomyelitis. Based on the areas under the curve, ESR is an ‘excellent’ biomarker to detect osteomyelitis, and CRP and PCT are ‘acceptable’ biomarkers to diagnose osteomyelitis. Diagnostic odds ratios indicate that ESR, CRP and PCT are ‘good’ or ‘very good’ tools to identify osteomyelitis.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Update of biomarkers to diagnose diabetic foot osteomyelitis: A meta‐analysis and systematic review

Ansert,

Tarricone,

Coye

et al. 2024

Wound Repair Regeneration

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“…The authors reported that on follow-up, after proper treatment (with antibiotics and any required surgery), the presence of radiologic changes during the DFO clinical remission was significantly associated with the development of complications. Similarly, another recent retrospective review of 46 patients found that taking serial radiographs had an 80% diagnostic accuracy, with an 87% positive predictive value and 43% negative predictive value for diagnosing OM ( p < 0.05) [ 96 ]. These results suggest that serial plain radiographs may be useful for both diagnosing OM and predicting complications.…”

Section: Clinical Questions and Practical Recommendationsmentioning

confidence: 99%

Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance

Lauri,

Noriega-Álvarez,

Chakravartty

et al. 2024

Eur J Nucl Med Mol Imaging

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Purpose Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings. Methods This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem–Intervention/Indicator–Comparator–Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria. Results Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging. Conclusion These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.

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“…Because plain X-rays are insensitive to acute osteomyelitis, it is often useful to repeat a normal examination in 2-3 weeks when the suspicion of osteomyelitis is still high. 93 A retrospective study of patients with histologically proven DFO found that after adjusting for confounders, inflammatory biomarkers, and plain X-rays were actually more useful than MRI. 94 Because interpretation of plain X-rays can be difficult (even for an experienced reader) when non-infectious changes (especially those related to neuro-osteoarthropathy) are present, advanced imaging techniques or even bone culture may ultimately be needed to confirm or exclude osteomyelitis in the foot.…”

Section: Rationalementioning

confidence: 99%

“…In addition, the image can be used as a reference against which to compare new images if the patient presents with another foot problem. Because plain X‐rays are insensitive to acute osteomyelitis, it is often useful to repeat a normal examination in 2–3 weeks when the suspicion of osteomyelitis is still high 93 . A retrospective study of patients with histologically proven DFO found that after adjusting for confounders, inflammatory biomarkers, and plain X‐rays were actually more useful than MRI 94 .…”

Section: Recommendationsmentioning

confidence: 99%

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes‐related foot infections (IWGDF/IDSA 2023)

Senneville,

Albalawi,

van Asten

et al. 2023

Diabetes Metabolism Res

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The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the management and prevention of diabetes‐related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus.The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient‐important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes‐related foot care to inform clinical care around patient‐important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations.The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes‐related foot problems.We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes‐related foot disease.

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The Role of Serial Radiographs to Diagnose Diabetic Foot Bone Infection.

Cited by 7 publications

References 30 publications

Update of biomarkers to diagnose diabetic foot osteomyelitis: A meta‐analysis and systematic review

Update of biomarkers to diagnose diabetic foot osteomyelitis: A meta‐analysis and systematic review

Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes‐related foot infections (IWGDF/IDSA 2023)

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