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.

Keywords: Diagnosis of infection; Guideline; Imaging; Osteitis; Osteomyelitis; Peripheral bone infection.

Fig. 1

The suggested initial diagnostic steps to undertake in the suspicion of PBI, based on published evidence. Of course not all steps are required, this may change in the individual patient. Some steps can of course be repeated when necessary. Serological tests can be performed over time since the trend to increase or decrease is more important than a single value. At this moment, there is not enough clinical evidence to support the use of one advanced diagnostic imaging technique above the other. There is a lack of studies with large patient numbers and there are hardly no comparative studies. Therefore, the choice of which advanced diagnostic modality to be used first depends on several factors, such as experience of the imaging specialist, costs, availability, radiation burden and local expertise (see also Tables 1 and 2). In many hospitals, MRI is considered as the first advanced imaging modality in daily practice, mainly because there is no radiation involved. In patients with metallic hardware, however, there is sufficient literature to support a preferential use of white blood cell scintigraphy

Fig. 2

The suggested path to undertake when nuclear-medicine techniques are considered in the suspicion of PBI, based on published evidence and expert opinion. This flowchart indicates when to use which nuclear imaging modality and is based on scientific evidence as mentioned in the statements