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Singh KB, London KI. 18F-FDG PET/CT in paediatric Staphylococcus aureus bacteraemia. J Paediatr Child Health 2024. [PMID: 38700132 DOI: 10.1111/jpc.16560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/28/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Karan Bir Singh
- Department of Nuclear Medicine, The Children's Hospital Westmead, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Kevin I London
- Department of Nuclear Medicine, The Children's Hospital Westmead, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
- Discipline of Medical Imaging Science, Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Kaasch AJ, López-Cortés LE, Rodríguez-Baño J, Cisneros JM, Dolores Navarro M, Fätkenheuer G, Jung N, Rieg S, Lepeule R, Coutte L, Bernard L, Lemaignen A, Kösters K, MacKenzie CR, Soriano A, Hagel S, Fantin B, Lafaurie M, Talarmin JP, Dinh A, Guimard T, Boutoille D, Welte T, Reuter S, Kluytmans J, Martin ML, Forestier E, Stocker H, Vitrat V, Tattevin P, Rommerskirchen A, Noret M, Adams A, Kern WV, Hellmich M, Seifert H. Efficacy and safety of an early oral switch in low-risk Staphylococcus aureus bloodstream infection (SABATO): an international, open-label, parallel-group, randomised, controlled, non-inferiority trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:523-534. [PMID: 38244557 DOI: 10.1016/s1473-3099(23)00756-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Staphylococcus aureus bloodstream infection is treated with at least 14 days of intravenous antimicrobials. We assessed the efficacy and safety of an early switch to oral therapy in patients at low risk for complications related to S aureus bloodstream infection. METHODS In this international, open-label, randomised, controlled, non-inferiority trial done in 31 tertiary care hospitals in Germany, France, the Netherlands, and Spain, adult patients with low-risk S aureus bloodstream infection were randomly assigned after 5-7 days of intravenous antimicrobial therapy to oral antimicrobial therapy or to continue intravenous standard therapy. Randomisation was done via a central web-based system, using permuted blocks of varying length, and stratified by study centre. The main exclusion criteria were signs and symptoms of complicated S aureus bloodstream infection, non-removable foreign devices, and severe comorbidity. The composite primary endpoint was the occurrence of any complication related to S aureus bloodstream infection (relapsing S aureus bloodstream infection, deep-seated infection, and mortality attributable to infection) within 90 days, assessed in the intention-to-treat population by clinical assessors who were masked to treatment assignment. Adverse events were assessed in all participants who received at least one dose of study medication (safety population). Due to slow recruitment, the scientific advisory committee decided on Jan 15, 2018, to stop the trial after 215 participants were randomly assigned (planned sample size was 430 participants) and to convert the planned interim analysis into the final analysis. The decision was taken without knowledge of outcome data, at a time when 126 participants were enrolled. The new sample size accommodated a non-inferiority margin of 10%; to claim non-inferiority, the upper bound of the 95% CI for the treatment difference (stratified by centre) had to be below 10 percentage points. The trial is closed to recruitment and is registered with ClinicalTrials.gov (NCT01792804), the German Clinical trials register (DRKS00004741), and EudraCT (2013-000577-77). FINDINGS Of 5063 patients with S aureus bloodstream infection assessed for eligibility, 213 were randomly assigned to switch to oral therapy (n=108) or to continue intravenous therapy (n=105). Mean age was 63·5 (SD 17·2) years and 148 (69%) participants were male and 65 (31%) were female. In the oral switch group, 14 (13%) participants met the primary endpoint versus 13 (12%) in the intravenous group, with a treatment difference of 0·7 percentage points (95% CI -7·8 to 9·1; p=0·013). In the oral switch group, 36 (34%) of 107 participants in the safety population had at least one serious adverse event compared with 27 (26%) of 103 participants in the intravenous group (p=0·29). INTERPRETATION Oral switch antimicrobial therapy was non-inferior to intravenous standard therapy in participants with low-risk S aureus bloodstream infection. However, it is necessary to carefully assess patients for signs and symptoms of complicated S aureus bloodstream infection at the time of presentation and thereafter before considering early oral switch therapy. FUNDING Deutsche Forschungsgemeinschaft. TRANSLATIONS For the German, Spanish, French and Dutch translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Achim J Kaasch
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany.
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS)/CSIC, Department of Medicine, Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS)/CSIC, Department of Medicine, Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - José Miguel Cisneros
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS)/CSIC, Department of Medicine, Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - M Dolores Navarro
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS)/CSIC, Department of Medicine, Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Gerd Fätkenheuer
- Department I of Internal Medicine, University Clinics, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, University Clinics, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, University Medical Centre Freiburg, Freiburg, Germany
| | - Raphaël Lepeule
- Antimicrobial Stewardship Team, Department of Prevention, Diagnosis, and Treatment of Infections, Henri-Mondor University Hospital, Creteil, France
| | - Laetitia Coutte
- Antimicrobial Stewardship Team, Department of Prevention, Diagnosis, and Treatment of Infections, Henri-Mondor University Hospital, Creteil, France
| | - Louis Bernard
- Service de Médecine Interne et Maladies Infectieuses, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Adrien Lemaignen
- Service de Médecine Interne et Maladies Infectieuses, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Katrin Kösters
- Medical Clinic II-Clinic for Gastroenterology, Hepatology, Neurogastroenterology, Infectious Diseases, Hematology, Oncology and Palliative Medicine, Helios Klinikum Krefeld, Krefeld, Germany
| | - Colin R MacKenzie
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), CIBERINFEC, Barcelona, Spain
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
| | - Bruno Fantin
- Internal Medicine Department, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris, Clichy, France
| | | | | | - Aurélien Dinh
- Infectious Diseases Department, Raymond-Poincaré University Hospital, Garches, France
| | - Thomas Guimard
- Infectious Diseases Department, CHD Vendée, La Roche-sur-Yon, France
| | - David Boutoille
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Tobias Welte
- Clinic for Respiratory Medicine and Infectious Diseases, Member of the German Center of Lung Research, Medical School Hannover, Hannover, Germany
| | - Stefan Reuter
- Department of Infectious Diseases and General Internal Medicine, Department of Infection Control, Klinikum Leverkusen, Leverkusen, Germany
| | - Jan Kluytmans
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Maria Luisa Martin
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitari Son Espases, Fundació Institut d'Investigació Sanitària Illes Balears, Palma de Mallorca, Spain
| | - Emmanuel Forestier
- Infectious Diseases Department, Centre Hospitalier Métropole Savoie, Chambéry, France
| | - Hartmut Stocker
- Klinik für Infektiologie, St Joseph Hospital Berlin Tempelhof, Berlin, Germany
| | - Virginie Vitrat
- Infectious Diseases Unit, Centre Hospitalier d'Annecy Genevois, Epagny Metz-Tessy, France
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Anna Rommerskirchen
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marion Noret
- French National Network of Clinical Research in Infectious Diseases, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, University Medical Centre Freiburg, Freiburg, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany; Institute of Translational Research, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
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González MI, González-Arjona M, Cussó L, Morcillo MÁ, Aguilera-Correa JJ, Esteban J, Kestler M, Calle D, Cerón C, Cortes-Canteli M, Muñoz P, Bouza E, Desco M, Salinas B. In Vivo Detection of Staphylococcus aureus Infections Using Radiolabeled Antibodies Specific for Bacterial Toxins. Int J Biomed Imaging 2024; 2024:3655327. [PMID: 38665417 PMCID: PMC11045290 DOI: 10.1155/2024/3655327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/02/2024] [Accepted: 01/13/2024] [Indexed: 04/28/2024] Open
Abstract
Purpose The Gram-positive Staphylococcus aureus bacterium is one of the leading causes of infection in humans. The lack of specific noninvasive techniques for diagnosis of staphylococcal infection together with the severity of its associated complications support the need for new specific and selective diagnostic tools. This work presents the successful synthesis of an immunotracer that targets the α-toxin released by S. aureus. Methods [89Zr]Zr-DFO-ToxAb was synthesized based on radiolabeling an anti-α-toxin antibody with zirconium-89. The physicochemical characterization of the immunotracer was performed by high-performance liquid chromatography (HPLC), radio-thin layer chromatography (radio-TLC), and electrophoretic analysis. Its diagnostic ability was evaluated in vivo by positron emission tomography/computed tomography (PET/CT) imaging in an animal model of local infection-inflammation (active S. aureus vs. heat-killed S. aureus) and infective osteoarthritis. Results Chemical characterization of the tracer established the high radiochemical yield and purity of the tracer while maintaining antibody integrity. In vivo PET/CT image confirmed the ability of the tracer to detect active foci of S. aureus. Those results were supported by ex vivo biodistribution studies, autoradiography, and histology, which confirmed the ability of [89Zr]Zr-DFO-ToxAb to detect staphylococcal infectious foci, avoiding false-positives derived from inflammatory processes. Conclusions We have developed an immuno-PET tracer capable of detecting S. aureus infections based on a radiolabeled antibody specific for the staphylococcal alpha toxins. The in vivo assessment of [89Zr]Zr-DFO-ToxAb confirmed its ability to selectively detect staphylococcal infectious foci, allowing us to discern between infectious and inflammatory processes.
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Affiliation(s)
- María Isabel González
- Unidad de Medicina y Cirugía Experimental, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
| | - Mario González-Arjona
- Unidad de Medicina y Cirugía Experimental, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28007 Madrid, Spain
| | - Lorena Cussó
- Unidad de Medicina y Cirugía Experimental, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
- CIBER de Salud Mental, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Miguel Ángel Morcillo
- Unidad de Aplicaciones Médicas de las Radiaciones Ionizantes, Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), 28040 Madrid, Spain
| | - John Jairo Aguilera-Correa
- Departamento de Química en Ciencias Farmacéuticas, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Servicio de Microbiología Clínica Instituto de Investigación Sanitaria Fundación Jiménez Díaz, UAM, 28040 Madrid, Spain
- CIBERINFEC-CIBER de Enfermedades Infecciosas, Madrid, Spain
| | - Jaime Esteban
- Servicio de Microbiología Clínica Instituto de Investigación Sanitaria Fundación Jiménez Díaz, UAM, 28040 Madrid, Spain
- CIBERINFEC-CIBER de Enfermedades Infecciosas, Madrid, Spain
| | - Martha Kestler
- Servicio de Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Daniel Calle
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
| | - Carlos Cerón
- Cardiovascular Risk Factors and Brain Function Programme, Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, 28029 Madrid, Spain
| | - Marta Cortes-Canteli
- Cardiovascular Risk Factors and Brain Function Programme, Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), 28040 Madrid, Spain
| | - Patricia Muñoz
- CIBER de Salud Mental, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Servicio de Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Emilio Bouza
- CIBER de Salud Mental, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Servicio de Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Manuel Desco
- Unidad de Medicina y Cirugía Experimental, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
- CIBER de Salud Mental, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, 28911 Madrid, Spain
| | - Beatriz Salinas
- Unidad de Medicina y Cirugía Experimental, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
- CIBER de Salud Mental, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, 28911 Madrid, Spain
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Schattner A, Dubin I, Uliel L, Finn T. Staphylococcus aureus bacteraemia presenting as sternoclavicular arthritis. QJM 2023; 116:1013-1015. [PMID: 37669140 DOI: 10.1093/qjmed/hcad193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Indexed: 09/07/2023] Open
Affiliation(s)
- A Schattner
- Department of Medicine, Laniado University Hospital, Sanz Medical Center, Netanya, Israel
- The Faculty of Medicine, Hebrew University Hadassah Medical School, Jerusalem, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - I Dubin
- Department of Medicine, Laniado University Hospital, Sanz Medical Center, Netanya, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - L Uliel
- Adelson School of Medicine, Ariel University, Ariel, Israel
- Department of Imaging, Laniado University Hospital, Sanz Medical Center, Netanya, Israel
| | - T Finn
- Adelson School of Medicine, Ariel University, Ariel, Israel
- Department of Infectious Diseases, Laniado University Hospital, Sanz Medical Center, Netanya, Israel
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Minter DJ, Appa A, Chambers HF, Doernberg SB. Contemporary Management of Staphylococcus aureus Bacteremia-Controversies in Clinical Practice. Clin Infect Dis 2023; 77:e57-e68. [PMID: 37950887 DOI: 10.1093/cid/ciad500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Indexed: 11/13/2023] Open
Abstract
Staphylococcus aureus bacteremia (SAB) carries a high risk for excess morbidity and mortality. Despite its prevalence, significant practice variation continues to permeate clinical management of this syndrome. Since the publication of the 2011 Infectious Diseases Society of America (IDSA) guidelines on management of methicillin-resistant Staphylococcus aureus infections, the field of SAB has evolved with the emergence of newer diagnostic strategies and therapeutic options. In this review, we seek to provide a comprehensive overview of the evaluation and management of SAB, with special focus on areas where the highest level of evidence is lacking to inform best practices.
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Affiliation(s)
- Daniel J Minter
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ayesha Appa
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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van der Vaart TW, Fowler VG. Positron emission tomography-computed tomography in patients with Staphylococcus aureus bacteraemia: worth the wait? Clin Microbiol Infect 2023; 29:1361-1363. [PMID: 37541582 DOI: 10.1016/j.cmi.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/06/2023]
Affiliation(s)
| | - Vance G Fowler
- Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University, Durham, NC, USA.
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Ong SWX, Zhabokritsky A, Daneman N, Tong SYC, Wijeysundera HC. Evaluating the use of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in the workup of Staphylococcus aureus bacteraemia: a cost-utility analysis. Clin Microbiol Infect 2023; 29:1417-1423. [PMID: 37353076 DOI: 10.1016/j.cmi.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/12/2023] [Accepted: 06/17/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVES The use of positron emission tomography/computed tomography (PET/CT) in the evaluation of patients with Staphylococcus aureus bacteraemia can improve the diagnosis of infectious foci and guide clinical management. We aimed to evaluate the cost-utility of PET/CT among adults hospitalized with Staphylococcus aureus bacteraemia. METHODS A cost-utility analysis was conducted from the healthcare payer perspective using a probabilistic Markov cohort model assessing three diagnostic strategies: (a) PET/CT in all patients, (b) PET/CT in high-risk patients only, and (c) routine diagnostic workup. Primary outcomes were quality-adjusted life years (QALYs), costs in Canadian dollars, and an incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analyses were conducted to evaluate parameter uncertainty. RESULTS Routine workup resulted in an average of 16.64 QALYs from the time of diagnosis at a lifetime cost of $209 060/patient. This was dominated by PET/CT in high-risk patients (i.e. greater effectiveness at lower costs) with average 16.88 QALYs at a cost of $199 552. Compared with PET/CT in high-risk patients only, PET/CT for all patients cost on average $11 960 more but resulted in 0.14 more QALYs, giving an incremental cost-effectiveness ratio of $83 500 (cost per additional QALY gained); however, there was a high degree of uncertainty comparing these two strategies. At a willingness-to-pay threshold of $50 000/QALY, PET/CT in high-risk patients was the most cost-effective strategy in 58.6% of simulations vs. 37.9% for PET/CT in all patients. DISCUSSION Our findings suggest that a strategy of using PET/CT in high-risk patients is more cost-effective than no PET/CT. Randomized controlled trials should be conducted to evaluate the use of PET/CT in different patient groups.
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Affiliation(s)
- Sean W X Ong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.
| | - Alice Zhabokritsky
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Nick Daneman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Ghanem-Zoubi N, Abu-Elhija J, Kagna O, Mustafa-Hellou M, Qasum M, Haber D, Paul M, Keidar Z. Predictors of infectious foci on FDG PET/CT in Staphylococcus aureus bacteremia. Sci Rep 2023; 13:14063. [PMID: 37640802 PMCID: PMC10462707 DOI: 10.1038/s41598-023-41336-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023] Open
Abstract
We looked for predicting factors for the detection of infectious foci on 18F-fluorodeoxyglucose-positron emission tomography in combination with computed tomography (FDG PET/CT) among patients with Staphylococcus aureus bacteremia (SAB) who participated in an interventional study that was conducted at Rambam Health Care Campus, between July 1, 2015 and February 1, 2019. The primary outcome was an infectious focus detected by FDG PET/CT. Independent predictors for detection of focal infection were identified using univariate followed by a logistic regression multivariate analysis. We included 149 patients with 151 separate episodes of SAB who underwent FDG-PET/CT. Focal infections were detected in 107 patients (70.8%). Independent predictors for focal infection detection were community acquisition of bacteremia with odds ratio (OR) 3.03 [95% confidence interval (CI) 1.04-8.77], p-0.042 and C reactive protein (CRP) with OR 1.09 [95% CI 1.04-1.14], p < 0.001. Primary bacteremia was inversely associated with focal infection detection with OR 0.27 [0.10-0.69], p = 0.007, as were the pre-scan blood glucose levels OR 0.9 [0.98-0.99], p-0.004. The latter stayed significant in the subgroup of patients with diabetes mellitus. To conclude, patients with community-acquired bacteremia or high CRP levels should be carefully investigated for focal infection. Patients who present with primary bacteremia seem to be at low risk for focal infection.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel.
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - Jawad Abu-Elhija
- Internal Medicine Department E, Rambam Health Care Campus, Haifa, Israel
| | - Olga Kagna
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Mona Mustafa-Hellou
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel
| | - Majd Qasum
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Daniel Haber
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Zohar Keidar
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
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Aguilera-Correa JJ, Salinas B, González-Arjona M, de Pablo D, Muñoz P, Bouza E, Fernández Aceñero MJ, Esteban J, Desco M, Cussó L. Positron Emission Tomography-Computed Tomography and Magnetic Resonance Imaging Assessments in a Mouse Model of Implant-Related Bone and Joint Staphylococcus aureus Infection. Microbiol Spectr 2023; 11:e0454022. [PMID: 37010409 PMCID: PMC10269916 DOI: 10.1128/spectrum.04540-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/04/2023] [Indexed: 04/04/2023] Open
Abstract
Osteomyelitis is an infection of the bone, associated with an inflammatory process. Imaging plays an important role in establishing the diagnosis and the most appropriate patient management. However, data are lacking regarding the use of preclinical molecular imaging techniques to assess osteomyelitis progression in experimental models. This study aimed to compare structural and molecular imaging to assess disease progression in a mouse model of implant-related bone and joint infections caused by Staphylococcus aureus. In SWISS mice, the right femur was implanted with a resorbable filament impregnated with S. aureus (infected group, n = 10) or sterile culture medium (uninfected group, n = 6). Eight animals (5 infected, 3 uninfected) were analyzed with magnetic resonance imaging (MRI) at 1, 2, and 3 weeks postintervention, and 8 mice were analyzed with [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET)-computed tomography (CT) at 48 h and at 1, 2, and 3 weeks postintervention. In infected animals, CT showed bone lesion progression, mainly in the distal epiphysis, although some uninfected animals presented evident bone sequestra at 3 weeks. MRI showed a lesion in the articular area that persisted for 3 weeks in infected animals. This lesion was smaller and less evident in the uninfected group. At 48 h postintervention, FDG-PET showed higher joint uptake in the infected group than in the uninfected group (P = 0.025). Over time, the difference between groups increased. These results indicate that FDG-PET imaging was much more sensitive than MRI and CT for differentiating between infection and inflammation at early stages. FDG-PET clearly distinguished between infection and postsurgical bone healing (in uninfected animals) from 48 h to 3 weeks after implantation. IMPORTANCE Our results encourage future investigations on the utility of the model for testing different therapeutic procedures for osteomyelitis.
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Affiliation(s)
- J. J. Aguilera-Correa
- Departamento de Química en Ciencias Farmacéuticas. Universidad Complutense de Madrid, Madrid, Spain
- CIBERINFEC-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - B. Salinas
- Unidad de Medicina y Cirugía Experimenta, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- CIBER de Salud Mental, Instituto de Salud Carlos III. Madrid, Spain
| | - M. González-Arjona
- Unidad de Medicina y Cirugía Experimenta, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - D. de Pablo
- Servicio de Anatomía Patológica Hospital Clínico San Carlos, Fundación para la Investigación Biomédica HCSC, Madrid, Spain
| | - P. Muñoz
- Servicio de Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
- CIBER Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - E. Bouza
- Servicio de Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
- CIBER Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - M. J. Fernández Aceñero
- Servicio de Anatomía Patológica Hospital Clínico San Carlos, Fundación para la Investigación Biomédica HCSC, Madrid, Spain
| | - J. Esteban
- CIBERINFEC-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Clinical Microbiology Department, IIS-Fundacion Jimenez Diaz, UAM, Madrid, Spain
| | - M. Desco
- Unidad de Medicina y Cirugía Experimenta, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- CIBER de Salud Mental, Instituto de Salud Carlos III. Madrid, Spain
| | - L. Cussó
- Unidad de Medicina y Cirugía Experimenta, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Unidad de Imagen Avanzada, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- CIBER de Salud Mental, Instituto de Salud Carlos III. Madrid, Spain
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10
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Hess S. [18F]FDG-PET/CT in patients with bacteremia: Clinical impact on patient management and outcome. Front Med (Lausanne) 2023; 10:1157692. [PMID: 37064040 PMCID: PMC10095558 DOI: 10.3389/fmed.2023.1157692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/28/2023] [Indexed: 03/31/2023] Open
Abstract
Bacteremia is the presence of viable bacteria in the bloodstream, a complicated and potentially dangerous systemic medical condition that may range from asymptomatic and clinically relatively indolent cases to more severe bloodstream infection (BSI) and ultimately life-threatening septic shock with fatal outcome. BSI is classified as simple (bacteremia only) or complex (BSI with metastatic spread), and the morbidity is higher in the latter, probably due to insufficient eradication. Treatment of simple BSI is usually short-term antibiotic courses, whereas complex BSI with metastatic foci requires more advanced treatment including long-term antibiotics or invasive drainage to gain infection control. Thus, identifying metastatic infection has an important clinical impact but remains a challenge; only half of the patients progress to complex BSI, and many patients present without relevant signs or symptoms, so imaging is pivotal. This review summarizes the potential role and recommendations of [18F]FDG-PET/CT in BSI, based on the relatively sparse and heterogeneous literature. [18F]FDG-PET/CT should be considered in suspected complex BSI, in patients at high risk of metastatic spread, and in BSI in ICU patients. [18F]FDG-PET/CT has an impact on patient management, treatment strategy, and patient outcome, mainly by directing the diagnostic process toward more specific diagnostics or by modifying treatment regimens resulting in reduced relapse rates and reduced mortality. Finally, a negative scan may obviate the need for further workup.
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Affiliation(s)
- Søren Hess
- Department of Radiology and Nuclear Medicine, Esbjerg Hospital – University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- IRIS – Imaging Research Initiative Southwest, Esbjerg, Denmark
- *Correspondence: Søren Hess,
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11
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Goodman AL, Packham A, Sharkey AR, Cook GJR. Advanced Imaging for Detection of Foci of Infection in Staphylococcus aureus Bacteremia- Can a Scan Save Lives? Semin Nucl Med 2023; 53:175-183. [PMID: 36690574 PMCID: PMC10016027 DOI: 10.1053/j.semnuclmed.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/23/2023]
Abstract
Bloodstream infection or sepsis is a common cause of mortality globally. Staphylococcus aureus (S. aureus) is of particular concern, through its ability to seed metastatic infections in almost any organ after entering the bloodstream (S. aureus bacteraemia), often without localising signs. A positive blood culture for S. aureus bacteria should lead to immediate and urgent identification of the cause. Failure to detect a precise focus of infection is associated with higher mortality, sometimes despite appropriate antibiotics. This is likely due to the limited ability to effectively target therapy in occult lesions. Early detection of foci of metastatic S. aureus infection is therefore key for optimal diagnosis and subsequent therapeutic management. 18F-FDG-PET/CT and MRI offer us invaluable tools in the localisation of foci of S. aureus infection. Crucially, they may identify unexpected foci at previously unsuspected locations in the body, for example vertebral osteomyelitis in the absence of back pain. S. aureus bloodstream infections are further complicated by their microbiological recurrence; 18F-FDG-PET/CT provide a means of localising, thus enabling source control. More evidence is emerging as to the utility of 18F-FDG-PET/CT in this setting, perhaps even to the point of reducing mortality. 18 F-FDG-PET/MRI may have a similar impact. The available evidence demonstrates a need to investigate the impact of 18F-FDG-PET/CT and MRI scanning in clinical management and outcomes of S. aureus infection further in a randomised prospective clinical trial.
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Affiliation(s)
- Anna L Goodman
- Medical Research Council Clinical Trials Unit at University College London, UK; Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Alice Packham
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK; Clinical Research Facility, University Hospitals Birmingham Foundation Trust, London, UK
| | - Amy R Sharkey
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gary J R Cook
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; King's College London and Guy's and St Thomas' PET Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
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12
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Cuervo G. PET/CT to diagnose and manage patients with infectious diseases: "¡vamos a brillar, mi amor! (Let's shine, my love!)". ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023; 41:1-2. [PMID: 36621242 DOI: 10.1016/j.eimce.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Guillermo Cuervo
- Department of Infectious Diseases, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.
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13
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Lam JC, Stokes W. The Golden Grapes of Wrath - Staphylococcus aureus Bacteremia: A Clinical Review. Am J Med 2023; 136:19-26. [PMID: 36179908 DOI: 10.1016/j.amjmed.2022.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022]
Abstract
Staphylococcus aureus bacteremia is common and associated with fatality rates approximating 25%. We provide a brief overview of S. aureus bacteremia from a clinical and microbiological lens and review the relevant evidence and literature gaps in its management. Using a case-based approach, evidence and clinical judgement are meshed to highlight and justify the 5 core interventions that ought to be performed for all cases of S. aureus bacteremia: 1) appropriate anti-staphylococcal therapy, 2) screening echocardiography, 3) assessment for metastatic phenomena and source control, 4) decision on duration of antimicrobial therapy, and 5) Infectious Diseases consultation.
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Affiliation(s)
- John C Lam
- Division of Infectious Diseases, Department of Medicine, University of California Los Angeles.
| | - William Stokes
- Provincial Laboratory for Public Health, Alberta Precision Laboratories, Alberta, Canada; Department of Pathology and Laboratory Medicine; Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
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14
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Medvedeva N, Radcliffe C, Malinis M, Chen MK, Azar MM. Real-world assessment of the clinical utility of whole body 18F-FDG PET/CT in the diagnosis of infection. PLoS One 2022; 17:e0277403. [PMCID: PMC9662742 DOI: 10.1371/journal.pone.0277403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022] Open
Abstract
Few studies have aimed to capture the full spectrum of 18fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) use for evaluation of infections in a real-world context. We performed a retrospective chart review of hospitalized patients who underwent 18F-FDG PET/CT for the workup of infection between April, 2013 and September, 2019. The clinical indications for and impact of 18F-FDG PET/CT on diagnostic and antimicrobial management were evaluated across different infectious indications. Sixty-one patients met the inclusion criteria. The most common indication was identifying a source of a known infection (46%), followed by fever of unknown etiology (FUE)/fever of unknown origin (FUO) (38%), and other (16%). 18F-FDG PET/CT was determined to have had a diagnostic or management clinical impact for a total of 22 patients (36%) including 12/28 (43%) of patients with known infection, 7/23 (30%) of patients with FUE/FUO, and 3/10 (30%) of patients with other indications. 18F-FDG PET/CT confirmed suspected prosthetic endovascular infection for 6/16 (38%) patients. In this study,18F-FDG PET/CT led to a clinical impact on diagnostic and treatment management of hospitalized patients across a variety of syndromes and particularly for source identification in the setting of known infection.
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Affiliation(s)
- Natalia Medvedeva
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Christopher Radcliffe
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Maricar Malinis
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Ming-Kai Chen
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America
| | - Marwan M. Azar
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States of America
- * E-mail:
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15
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Cuervo G. PET/CT to diagnose and manage patients with infectious diseases: “¡vamos a brillar, mi amor! (Let's shine, my love!)”. Enferm Infecc Microbiol Clin 2022. [DOI: 10.1016/j.eimc.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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16
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Holland TL, Bayer AS, Fowler VG. Persistent Methicilin-Resistant Staphylococcus aureus Bacteremia: Resetting the Clock for Optimal Management. Clin Infect Dis 2022; 75:1668-1674. [PMID: 35535790 PMCID: PMC9617577 DOI: 10.1093/cid/ciac364] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 01/25/2023] Open
Abstract
A positive follow-up blood culture for methicillin-resistant Staphylococcus aureus (MRSA) while on seemingly appropriate therapy is a common and ominous development. However, the definition and management of persistent MRSA bacteremia is unstandardized. In this Opinion Paper, we identify the presence of bacteremia for > 1 calendar day as a "worry point" that should trigger an intensive diagnostic evaluation to identify metastatic infection sites. Next, we define the duration of MRSA bacteremia that likely constitutes antibiotic failure and outline a potential management algorithm for such patients. Finally, we propose pragmatic clinical trial designs to test treatment strategies for persistent MRSA bacteremia.
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Affiliation(s)
- Thomas L Holland
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Arnold S Bayer
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA, Torrance, California, USA
- The Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Vance G Fowler
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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17
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Yoo J, Cheon M. Septic Pulmonary Emboli Detected by 18F-FDG PET/CT in a Patient with Central Venous Catheter-Related Staphylococcus aureus Bacteremia. Diagnostics (Basel) 2022; 12:diagnostics12102479. [PMID: 36292168 PMCID: PMC9600020 DOI: 10.3390/diagnostics12102479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
We describe a case of 18F-FDG PET/CT detecting septic pulmonary emboli in a patient with Staphylococcus aureus catheter-related bloodstream infection (CRBSI). The patient, who had an implantable venous access port for chemotherapy, underwent 18F-FDG PET/CT to diagnose unsuspected infectious foci. The PET/CT examination made it possible to offer a suggestive diagnosis and yielded metastatic infectious foci.
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18
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Abstract
PURPOSE OF REVIEW To review recently published evidence relevant to Staphylococcus aureus bacteremia (SAB). RECENT FINDINGS Staphylococcus aureus is the most common pathogen causing co-infections and superinfections in patients with COVID-19. Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia ratios have sharply risen during the pandemic. SAB mortality is 18% at 1 month and 27% at 3 months but has gradually decreased over the last 30 years. Recurrences and reinfections are common (9%). Standardised items to define complicated SAB, and a new cut-off defining persisting bacteremia after 2 days with positive blood cultures have been proposed. Multiple antibiotic combinations have been trialled including vancomycin or daptomycin with β-lactams, fosfomycin, or clindamycin, without significant results. In the recently published guidelines, vancomycin remains the first line of treatment for MRSA bacteremia. For the management of methicillin-susceptible Staphylococcus aureus , cefazolin less frequently causes acute kidney injury than flucloxacillin, and when susceptibility is demonstrated, de-escalation to penicillin G is suggested. SUMMARY Our review confirms that Staphylococcus aureus represents a special aetiology among all causes of bloodstream infections. Pending results of platform and larger trials, its distinct epidemiology and determinants mandate careful integration of clinical variables and best available evidence to optimize patient outcomes.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Metro North Hospital and Health Services
- Queensland University of Technology
- Faculty of Medicine, University of Queensland
| | - Kevin B Laupland
- Queensland University of Technology
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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19
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Kouijzer IJE, Speijker LTD, Aarntzen EHJG, Rijnen WHC, Somford MP, Maat I, van Meer MPA, Oever JT, Gisolf EH. Clinically unsuspected orthopedic implants during S. aureus bacteremia do not require additional diagnostic work-up. Infection 2022; 51:743-747. [PMID: 36076049 DOI: 10.1007/s15010-022-01913-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/24/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the likelihood of occult infection in patients with clinically unsuspected orthopedic implants during Staphylococcus aureus bacteremia (SAB). METHODS In a retrospective study in two Dutch hospitals, we included all patients with SAB between 2013 and 2020 with one or more orthopedic implants in whom [18F]FDG-PET/CT was performed. The primary outcome was the percentage of patients who had an orthopedic implant-related infection by S. aureus. We also compared clinical parameters in patients with clinically suspected and unsuspected implants. RESULTS Fifty-five of 191 (29%) orthopedic implants in 118 SAB patients included had clinical signs of infection. Of all 136 unsuspected implants, 5 (3%, all arthroplasties), showed increased [18F]FDG uptake around the prosthesis on [18F]FDG-PET/CT. The clinical course of these patients without clinically overt infection or relapse of bacteremia during follow-up of a median of 48 months (range 0-48), however, argued against prosthetic joint infection. CONCLUSION Although orthopedic implants are evidently a risk factor for metastatic infection during SAB, the absence of clinical symptoms obviate the need of additional investigations or prolonged antibiotic treatment.
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Affiliation(s)
- Ilse J E Kouijzer
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - L T D Speijker
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - E H J G Aarntzen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - W H C Rijnen
- Department of Orthopaedics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M P Somford
- Department of Orthopaedics, Rijnstate Hospital, Arnhem, the Netherlands
| | - I Maat
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M P A van Meer
- Department of Medical Microbiology and Immunology, Rijnstate Hospital, Arnhem, the Netherlands
| | - J Ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - E H Gisolf
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands
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20
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Buis DTP, Prins JM, Betica-Radic L, de Boer MGJ, Ekkelenkamp M, Kofteridis D, Peiffer-Smadja N, Schouten J, Spernovasilis N, Tattevin P, ten Oever J, Sigaloff KCE. Current clinical practice in antibiotic treatment of Staphylococcus aureus bacteraemia: results from a survey in five European countries. J Antimicrob Chemother 2022; 77:2827-2834. [PMID: 35869753 PMCID: PMC9797040 DOI: 10.1093/jac/dkac237] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/17/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To determine clinical practice variation and identify knowledge gaps in antibiotic treatment of Staphylococcus aureus bacteraemia (SAB). METHODS A web-based survey with questions addressing antibiotic treatment of SAB was distributed through the ESGAP network among infectious disease specialists, clinical microbiologists and internists in Croatia, France, Greece, the Netherlands and the UK between July 2021 and November 2021. RESULTS A total number of 1687 respondents opened the survey link, of whom 677 (40%) answered at least one question. For MSSA and MRSA bacteraemia, 98% and 94% preferred initial monotherapy, respectively. In patients with SAB and non-removable infected prosthetic material, between 80% and 90% would use rifampicin as part of the treatment. For bone and joint infections, 65%-77% of respondents would consider oral step-down therapy, but for endovascular infections only 12%-32% would. Respondents recommended widely varying treatment durations for SAB with different foci of infection. Overall, 48% stated they used 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG-PET/CT) to guide antibiotic treatment duration. Persistent bacteraemia was the only risk factor for complicated SAB that would prompt a majority to extend treatment from 2 to 4-6 weeks. CONCLUSIONS This survey in five European countries shows considerable clinical practice variation between and within countries in the antibiotic management of SAB, in particular regarding oral step-down therapy, choice of oral antibiotic agents, treatment duration and use of 18F-FDG-PET/CT. Physicians use varying criteria for treatment decisions, as evidence from clinical trials is often lacking. These areas of practice variation could be used to prioritize future studies for further improvement of SAB care.
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Affiliation(s)
| | - J M Prins
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, De Boelelaan 1117, Amsterdam, The Netherlands
| | - L Betica-Radic
- General Hospital Dubrovnik, Department of Infectious Diseases, University of Dubrovnik, Dubrovnik, Croatia
| | - M G J de Boer
- Leiden University Medical Center, Department of Infectious Diseases, Leiden, The Netherlands
| | - M Ekkelenkamp
- UMC Utrecht, Department of Medical Microbiology, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - D Kofteridis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Greece
| | - N Peiffer-Smadja
- Infectious Disease Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - J Schouten
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - N Spernovasilis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Greece,Department of Infectious Diseases, German Oncology Center, Limassol, Cyprus
| | - P Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - J ten Oever
- Radboud University Medical Center, Department of Internal Medicine and Radboud Center for Infectious Diseases, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - K C E Sigaloff
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, De Boelelaan 1117, Amsterdam, The Netherlands
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21
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Thottacherry E, Cortés-Penfield NW. Evidence of clinical impact supports a new petition for Medicare coverage of 18F-FDG-PET/CT in the evaluation of Staphylococcus aureus bacteremia: a focused literature review and call to action. Clin Infect Dis 2022; 75:1457-1461. [PMID: 35535794 DOI: 10.1093/cid/ciac363] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Indexed: 12/13/2022] Open
Abstract
Staphylococcus aureus bacteremia (SAB) causes considerable morbidity and mortality and requires comprehensive assessment for metastatic infection. The roles of routine imaging beyond echocardiography in SAB, including 18F-FDG-PET/CT, remain contentious. We performed a literature review of studies reporting impact of 18F-FDG-PET/CT on the clinical management or outcomes of SAB published through 3/1/2022. We identified seven observational studies, in which 18F-FDG-PET/CT frequently identified metastatic foci of infection, revealed foci undetected by prior investigations, led to additional source control procedures, and was associated with fewer infection relapses and lower mortality. Calculated numbers needed to treat (NNTs) for receipt of 18F-FDG-PET/CT were 7-9 to change antimicrobial therapy, 10-27 to lead to an additional source control procedure, and 4-8 to prevent death. These data are comparable to the evidence for clinical impact of other diagnostic modalities accepted as standard of care in SAB, and form a compelling basis for advocacy to expand access to 18F-FDG-PET/CT.
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Affiliation(s)
- Elizabeth Thottacherry
- Division of Infectious Diseases, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
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22
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Buis DTP, Sieswerda E, Kouijzer IJE, Huynh WY, Burchell GL, Berrevoets MAH, Prins JM, Sigaloff KCE. [18F]FDG-PET/CT in Staphylococcus aureus bacteremia: a systematic review. BMC Infect Dis 2022; 22:282. [PMID: 35331165 PMCID: PMC8943998 DOI: 10.1186/s12879-022-07273-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/04/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES [18F]FDG-PET/CT is used for diagnosing metastatic infections in Staphylococcus aureus bacteremia (SAB) and guidance of antibiotic treatment. The impact of [18F]FDG-PET/CT on outcomes remains to be determined. The aim of this systematic review was to summarize the effects of [18F]FDG-PET/CT on all-cause mortality and new diagnostic findingsin SAB. METHODS We systematically searched PubMed, EMBASE.com, Web of Science, and Wiley's Cochrane library from inception to 29 January 2021. Eligible studies were randomized controlled trials, clinically controlled trials, prospective and retrospective cohort studies, and case-control studies investigating the effects of [18F]FDG-PET/CT in hospitalized adult patients with SAB. We excluded studies lacking a control group without [18F]FDG-PET/CT. Risk of bias was assessed using the ROBINS-I tool and certainty of evidence using the GRADE approach by two independent reviewers. RESULTS We identified 1956 studies, of which five were included in our qualitative synthesis, including a total of 880 SAB patients. All studies were non-randomized and at moderate or serious risk of bias. Four studies, including a total of 804 patients, reported lower mortality in SAB patients that underwent [18F]FDG-PET/CT. One study including 102 patients reported more detected metastatic foci in the participants in whom [18F]FDG-PET/CT was performed. DISCUSSION We found low certainty of evidence that [18F]FDG-PET/CT reduces mortality in patients with SAB. This effect is possibly explained by a higher frequency of findings guiding optimal antibiotic treatment and source control interventions.
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Affiliation(s)
- D T P Buis
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
| | - E Sieswerda
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - I J E Kouijzer
- Radboudumc, Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - W Y Huynh
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - G L Burchell
- Medical Library, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - M A H Berrevoets
- Department of Internal Medicine, Division of Infectious Diseases, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - K C E Sigaloff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
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Individualizing the use of [ 18F]FDG-PET/CT in patients with complicated Staphylococcus aureus bacteremia: experiences from a tertiary care center. Infection 2021; 50:491-498. [PMID: 34928493 PMCID: PMC8942890 DOI: 10.1007/s15010-021-01740-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
Purpose [18F]FDG-PET/CT scanning can help detect metastatic infectious foci and reduce mortality in patients with Staphylococcus aureus bacteremia (SAB), but it is unknown if patients with SAB and an indication for prolonged treatment because of possible endovascular, orthopaedic implant, or other metastatic infection still need [18F]FDG-PET/CT. Methods In a retrospective single-center cohort study, we included all consecutive adult patients with SAB between 2013 and 2020 if an [18F]FDG-PET/CT scan was performed and antibiotic treatment was planned for ≥ 6 weeks prior to [18F]FDG-PET/CT. We aimed to identify patients for whom treatment was adjusted due to the results of [18F]FDG-PET/CT, and assessed concordance of [18F]FDG-PET/CT and clinical diagnosis for infected prosthetic material. Results Among 132 patients included, the original treatment plan was changed after [18F]FDG-PET/CT in 22 patients (16.7%), in the majority (n = 20) due to diagnosing or rejecting endovascular (graft) infection. Antibiotic treatment modifications were shortening in 2, iv-oral switch in 3, extension in 13, and addition of rifampicin in 4 patients. Ninety additional metastatic foci based on [18F]FDG-PET/CT results were found in 69/132 patients (52.3%). [18F]FDG-PET/CT suggested vascular graft infection in 7/14 patients who lacked clinical signs of infection, but showed no infection of prosthetic joints or osteosynthesis material in eight patients who lacked clinical signs of such an infection. Conclusion [18F]FDG-PET/CT can help refine treatment for SAB in patients with clinically suspected endovascular infection or vascular grafts, even if 6 weeks treatment is already indicated, but can be safely omitted in other patients who are clinically stable. Supplementary Information The online version contains supplementary material available at 10.1007/s15010-021-01740-4.
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Gompelman M, Tuinte R, Aarntzen E, Kouijzer I, van Leerdam E, Berrevoets M, Ten Oever J, Bleeker-Rovers C, Wanten G. The diagnostic value of [ 18F]FDG-PET/CT in detecting septic thrombosis in patients with central venous catheter-related Staphylococcus aureus bacteremia. Biomed Pharmacother 2021; 144:112296. [PMID: 34634557 DOI: 10.1016/j.biopha.2021.112296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/08/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Septic thrombosis often complicates Staphylococcus aureus bacteremia (SAB) in patients with a central venous catheter. Currently there is no reference standard for diagnosis. We describe the diagnostic value of [18F]FDG-PET/CT imaging in a patient cohort and the potential contribution of quantitative measurements in detecting septic thrombosis. METHODS We selected patients with catheter-related SAB from our institutional database (2013-2020). The contribution of [18F]FDG-PET/CT on clinical diagnosis of septic thrombosis was evaluated. Standardized Uptake Values (SUV) were measured and compared with a composite reference standard (clinical signs, initial [18F]FDG-PET/CT result, Multidisciplinary Team (MDT) meeting outcome) to identify a cut-off value for detecting septic thrombosis. RESULTS We identified 93 patients with a catheter-related SAB. Quantitative measurements were possible for 43/56 patients in whom a [18F]FDG-PET/CT scan was performed. Septic thrombosis was clinically diagnosed in 30% (13/43) of the cases. In 85% of these cases, significant [18F]FDG-PET/CT uptake at the site of the thrombus was the deciding factor for diagnosis of septic thrombosis during the MDT meeting. All mean SUV's of thrombotic lesions were higher in patients with clinically proven septic thrombosis compared to patients in whom this diagnosis was rejected (p < 0.001). A SUVpeak thrombus/SUVmean blood ratio of 1.6 (AUC-ROC value 0.982) as cut-off to differentiate between septic thrombosis and non-septic thrombosis had a sensitivity of 92% (95% CI 64-100) and specificity of 89% (95% CI 65-99). An algorithm was designed to guide diagnosis of septic thrombosis. CONCLUSION Quantitative [18F]FDG-PET/CT-derived parameters seem helpful to differentiate between septic and non-septic thrombosis in patients with catheter-related SAB.
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Affiliation(s)
- Michelle Gompelman
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Renée Tuinte
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erik Aarntzen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ilse Kouijzer
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eline van Leerdam
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marvin Berrevoets
- Department of Internal Medicine, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Chantal Bleeker-Rovers
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Geert Wanten
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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The Role of 18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) in Management of Nocardiosis: A Retrospective Study and Review of the Literature. Infect Dis Ther 2021; 10:2227-2246. [PMID: 34283408 PMCID: PMC8572926 DOI: 10.1007/s40121-021-00495-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/30/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction 18-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is a well-established tool for managing metastatic infections. Nocardiosis, a primarily pulmonary infection, disseminates at high rates. Routine imaging includes chest CT and brain imaging. We examined the use of FDG-PET/CT in nocardiosis and assessed its contribution to diagnosis and management. Methods A retrospective study in two tertiary medical centers during 2011–2020. Individuals with nocardiosis for whom FDG-PET/CT was implemented for any reason were included and their medical records were reviewed. A board-certified nuclear medicine physician independently reviewed all scans. Additionally, a systematic review was conducted according to the PRISMA guidelines, to extract data from publications reporting FDG-PET/CT use for the management of nocardiosis. Results FDG-PET/CT contributed to the management of all seven patients who met inclusion criteria. It assisted in ruling out an underlying malignancy (29%, 2/7); establishing a wide infection extent (57%, 4/7); and affecting decisions regarding treatment (57%, 4/7), including drug regimen, oral step-down, and duration of therapy. We identified 20 published case reports on this topic. In 80% (16/20), FDG-PET/CT contributed to the management of nocardiosis similar to our study. In addition, in most of the literature cases, FDG-PET/CT guided the diagnostic biopsy. Conclusion FDG-PET/CT is valuable in the diagnosis and management of individuals with nocardiosis. The contribution of incorporating FDG-PET/CT to the management of individuals with nocardiosis and its role in monitoring treatment response and shortening treatment duration should be evaluated in prospective studies.
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