title: Diagnosing diabetic foot osteomyelitis in patients without signs of soft tissue infection by coupling hybrid 67Ga SPECT/CT with bedside percutaneous bone puncture.
abstract: OBJECTIVE
  Successful treatment of osteomyelitis is more likely with accurate diagnosis and identification of the causative pathogens. This typically requires obtaining a specimen of bone, usually by image-guided biopsy. We sought to develop a simpler bedside method for definitively diagnosing osteomyelitis.
  
  
  METHODS
  Over 2 years, we enrolled consecutive patients presenting to our diabetic foot clinic with a foot ulcer and clinically suspected osteomyelitis but without soft tissue infection. Each underwent hybrid (67)Ga single-photon emission computed tomography and X-ray computed tomography (SPECT/CT) imaging; those with a positive scan underwent bedside percutaneous bone puncture. Patients with a positive bone culture received culture-guided antibiotic therapy. Patients with negative (67)Ga SPECT/CT imaging or with positive imaging but negative bone culture were not treated with antibiotics. All patients were followed up for ≥ 1 year.
  
  
  RESULTS
  Among 55 patients who underwent (67)Ga SPECT/CT imaging, 13 had negative results and all of their foot ulcers resolved without antibiotic therapy. Among 42 with positive imaging, 2 were excluded (for recent antibiotic therapy) and 40 had bone punctures (3 punctured twice): 19 had negative results, 3 of which were likely false negatives, and 24 had positive results (all gram-positive cocci). At follow-up, 3 patients had died, 3 had undergone amputation, and 47 had no evidence of foot infection. The sensitivity and specificity of this combined method were 88.0 and 93.6%, respectively, and the positive and negative predictive values were 91.7 and 90.7%, respectively.
  
  
  CONCLUSIONS
  Coupling of (67)Ga SPECT/CT imaging and bedside percutaneous bone puncture appears to be accurate and safe for diagnosing diabetic foot osteomyelitis in patients without signs of soft tissue infection, obviating the need for antibiotic treatment in 55% of suspected cases.
authors.affiliation: Université Paris Descartes, Paris, France. elisabeth.aslangul@htd.aphp.fr
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Aslangul
authors.forename: Jocelyne
authors.initials: J
authors.lastname: M'bemba
authors.forename: Nadine
authors.initials: N
authors.lastname: Caillat-Vigneron
authors.forename: Sophie
authors.initials: S
authors.lastname: Coignard
authors.forename: Etienne
authors.initials: E
authors.lastname: Larger
authors.forename: Christian
authors.initials: C
authors.lastname: Boitard
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: Lipsky
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001842:Bone and Bones / Q000000981:diagnostic imaging / Q000382:microbiology; D017719:Diabetic Foot / Q000150:complications / Q000000981:diagnostic imaging; D005710:Gallium Radioisotopes; D006801:Humans; D008297:Male; D008875:Middle Aged; D010019:Osteomyelitis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology; D019095:Point-of-Care Systems; D011237:Predictive Value of Tests; D011677:Punctures; D019275:Radiopharmaceuticals; D012680:Sensitivity and Specificity; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D005710:Gallium Radioisotopes; D019275:Radiopharmaceuticals