Abbreviations
- CT
Computed tomography
- DFI
Diabetic foot infection
- EANM
European Association of Nuclear Medicine
- EBJIS
European Bone and Joint Infection Society
- ESCMID
European Society of Microbiology and Infectious Disease
- ESR
European Society of Radiology
- IDSA
Infectious Diseases Society of America
- MRI
Magnetic resonance imaging
- NVO
Native vertebral osteomyelitis
- PBI
Peripheral bone infection
- PET
Positron emission tomography
- PRISMA
Preferred Reporting Items for Systematic Reviews and MetaAnalyses
- SPECT
Single-photon emission computed tomography
- UMHS
University of Michigan Health System
- WBC
White blood cell
Context and Policy Issues
Osteomyelitis is an inflammation of the bone due to infection caused by bacteria, commonly Staphylococcus aureus.1 Bacteria can reach the bone through various means including trauma, surgery, the blood stream, extension from an adjacent soft tissue infection, or diabetic foot infection.1 Osteomyelitis can occur at any age, although the incidence appears to peak at children under the age of five and in adults over 50 years of age.2 It can be classified as acute or chronic, based on histopathological findings.3 Factors associated with osteomyelitis include aging, increased prevalence of trauma, and increased prevalence of diabetic foot infection.4
Early detection of osteomyelitis will likely lead to more favorable outcomes.4 Diagnosis of osteomyelitis requires a multidisciplinary approach including clinical examination, recognition and assessment of clinical symptoms, laboratory investigations and imaging tests.4 There are various imaging modalities that have been used in the characterization and differential diagnosis of osteomyelitis, such as plain X-ray radiography, computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy, positron emission tomography (PET), single-photon emission computed tomography (SPECT), and ultrasonography.1,4 The diagnostic accuracies of these imaging tests for diagnosis of osteomyelitis have been systematically reviewed.5 Although plain X-ray radiography has lower sensitivity and specificity compared to other imaging tests, the American College of Radiology Appropriateness Criteria and reviews recommend that X-ray should be used as first line imaging modality to differentiate osteomyelitis from other clinical conditions such as bone fractures or bone malignancies.3,6,7 Plain X-ray radiography, whether or not with positive or negative results, is usually followed by higher sensitivity and specificity imaging modalities for diagnosis of osteomyelitis.8 However, in institutions where the availability of more sophisticated imaging modalities is limited, it is unclear if the use of serial X-ray radiography (i.e., initial assessment with X-rays followed by subsequent X-rays in 1 to 3 weeks), could improve diagnostic accuracy for detection of osteomyelitis.
The aim of this report is to review the diagnostic accuracy, clinical utility, and cost-effectiveness of serial X-ray radiography in adults with suspected osteomyelitis compared to other diagnostic modalities. This report also aims to identify evidence-based guidelines regarding the use of diagnostic modalities in adults with suspected osteomyelitis.
Research Question
What is the diagnostic accuracy of serial X-ray radiography in adults with suspected osteomyelitis?
What is the clinical utility of serial X-ray radiography in adults with suspected osteomyelitis?
What is the cost-effectiveness of serial X-ray radiography in adults with suspected osteomyelitis?
What are the evidence-based guidelines regarding the use of diagnostic modalities in adults with suspected osteomyelitis?
Key Findings
This review included three evidence-based guidelines for diagnosis of peripheral bone infection, diabetic foot infection, and native vertebral osteomyelitis in adults. No studies on the diagnostic accuracy, clinical utility and cost-effectiveness of serial X-ray radiography for diagnosis of osteomyelitis were identified.
All three guidelines were considered to be of good methodological quality. Based on moderate to low quality evidence, the guidelines had recommendations for diagnosis of osteomyelitis regarding medical examination, laboratory tests, bone biopsy and bone culture, and imaging tests. Bone biopsy and bone culture are considered as the reference standard to confirm the infection and identify the causative microorganism. Although magnetic resonance imaging, positron emission tomography and single-photon emission computed tomography were found to have higher diagnostic performance than radiography, it is recommended that conventional X-ray radiography should be the first imaging modality for detection of osteomyelitis, particularly for suspected peripheral bone infection or for osteomyelitis in diabetic foot infection. With suspected native vertebral osteomyelitis, spine magnetic resonance imaging, when feasible, is recommended as first imaging of choice. Subsequent imaging tests may be considered depending on the extent of the investigation, the availability of the imaging modalities, the level of diagnostic accuracy required, the complexity of the disease, and any contraindications.
There is a need for studies examining the diagnostic accuracy, clinical utility and cost-effectiveness of serial X-ray radiography for detection of osteomyelitis in adults.
Methods
Literature Search Methods
A limited literature search was conducted by an information specialist on key resources including PubMed, the Cochrane Library, the University of York Centre for Reviews and Dissemination (CRD) databases, the websites of Canadian and major international health technology agencies, as well as a focused Internet search. The search strategy was comprised of both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. The main search concepts were x-ray radiography and osteomyelitis. No filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2015 and February 14, 2020.
Selection Criteria and Methods
One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in .
Exclusion Criteria
Studies were excluded if they did not meet the selection criteria in or if they were published prior to 2015.
Critical Appraisal of Individual Studies
The included evidence-based guidelines were critically appraised using the Appraisal of Guidelines for Research and Development (AGREE) II instrument.9 Summary scores were not calculated for the included guidelines; rather, the strengths and limitations were described narratively.
Summary of Evidence
Quantity of Research Available
A total of 662 citations were identified in the literature search. Following screening of titles and abstracts, 641 citations were excluded and 21 potentially relevant reports from the electronic search were retrieved for full-text review. Two potentially relevant publications were retrieved from the grey literature search. Of the 23 potentially relevant articles, 20 publications were excluded for various reasons; three guidelines met the inclusion criteria and were included in this report. No studies reporting the diagnostic accuracy, clinical utility, or cost-effectiveness of serial X-ray radiography in adults with suspected osteomyelitis were identified. Appendix 1 presents the PRISMA flowchart10 of the study selection.
Summary of Study Characteristics
The detailed characteristics of the included guidelines11–13 () are presented in Appendix 2.
Study Design
The included guidelines were developed by: four European societies (European Bone and Joint Infection Society [EBJIS], European Society of Clinical Microbiology and Infectious Diseases [ESCMID], European Society of Radiology [ESR], and European Association of Nuclear Medicine [EANM]),11 the University of Michigan Health System (UMHS),12 and the Infectious Diseases Society of America (IDSA).13 All three included guidelines11–13 used systematic methods to search for, select, and synthesize evidence. The guidelines were developed by panels of experts in the field of osteomyelitis in general, or diabetic foot infection in particular. The recommendations were developed through discussion and consensus based on evidence level. The joint consensus statements in the EBJIS/ESCMID/ESR/EANM European guideline11 were rated with the associated level evidence, where level 1 represented for evidence from systematic reviews of randomized trials and level 5 from mechanism-based reasoning. In the UMHS guideline,12 the strength of recommendation (e.g., I = generally should be performed, II = may be reasonable to performed, and III = generally should not be performed) and level of evidence (level A = systematic reviews of randomized trials with or without meta-analysis, to level E = expert opinion) were provided for each recommendation statements. In the IDSA guideline,13 the recommendations were graded from strong to weak, while the quality of evidence was assessed as high quality to very low quality. The strength of recommendation and the quality of the evidence were presented together based on the clarity of balance between desirable and undesirable effects, the methodological quality of supporting evidence and implications of recommendations.13 All guidelines were peer-reviewed. Two guidelines were published in 201911,12 and one in 2015.13
Country of Origin
One guideline was developed in Europe,11 and two in the USA.12,13
Patient Population
The target populations for the identified guidelines was adult patients with a suspicion of peripheral bone infection,11 with diabetic foot infection,12 or with native vertebral osteomyelitis.13 The intended users of the guidelines were healthcare professionals.
Interventions and Comparators
The interventions considered in the guidelines were interventions for the diagnosis and management of adult patients with peripheral bone infection,11 diabetic foot infection,12 and native vertebral osteomyelitis.13 Imaging modalities mentioned in the guidelines included plain X-ray radiography, CT, MRI, PET, SPECT and scintigraphy. Serial X-ray radiography was not mentioned in any of the included guidelines.
Outcomes
All included guidelines had recommendations regarding the diagnosis of osteomyelitis, specifically peripheral bone infection,11 diabetic foot infections,12 or native vertebral osteomyelitis13 in adults. The guidelines considered all outcomes related to diagnosis and management of osteomyelitis, including clinical assessment, symptoms, signs, laboratory parameters, bone biopsy, and imaging tests. In addition to diagnostic outcomes, the availability of diagnostic procedures, patient acceptance, tolerability, complications, and costs were considered in developing the recommendations.
Summary of Critical Appraisal
The detailed quality assessments of the included guidelines11–13 () are presented in Appendix 3.
All three included guidelines11–13 were explicit in terms of scope and purpose (i.e., objectives, health questions and populations), and had clear presentation (i.e., specific and unambiguous recommendations, different options for management of the condition or health issue, and easy to find key recommendations). In terms of stakeholder involvement, the guidelines clearly defined target users and the development groups included individuals from all relevant professional groups, and sought the views and preferences of the target populations. For rigour of development, the guidelines explicitly reported details of systematic searches for evidence, criteria for selecting evidence, strengths and limitations of the body of evidence, methods of formulating the recommendations, health benefits, side effects, and risks in formulating the recommendations, and all were peer-reviewed prior to publication. Two guidelines11,12 provided a procedure for updating. For applicability, all guidelines were explicit in terms of facilitators and barriers to application, advice and/or tools on how the recommendations can be put into practice, resource (cost) implications, and monitoring and or auditing criteria. For editorial independence, it was unclear if the funding bodies influenced the content of the guidelines. The EBJIS/ESCMID/ESR/EANM European guideline11 did not mention its funding source, the UMHS guideline12 declared no financial support, and the IDSA guideline13 was funded its own organization. The competing interests of guideline development group members were reported in all three guidelines. Overall, all three included guidelines had good methodological quality.
Summary of Findings
Diagnostic Accuracy of Serial X-Ray Radiography
No studies regarding the diagnostic accuracy of serial X-ray radiography in adults with suspected osteomyelitis were identified; therefore, no summary can be provided.
Clinical Utility of Serial X-Ray Radiography
No studies regarding the clinical utility of serial X-ray radiography in adults with suspected osteomyelitis were identified; therefore, no summary can be provided.
Cost-Effectiveness of Serial X-Ray Radiography
No studies regarding the cost-effectiveness of serial X-ray radiography in adults with suspected osteomyelitis were identified; therefore, no summary can be provided.
Guidelines Regarding the Use of Diagnostic Modalities in Detecting Osteomyelitis in Adults
The key recommendations of the guidelines11–13 (Table 4) are presented in Appendix 4.
The joint EBJIS/ESCMID/ESR/EANM guideline provided recommendations specific to patients with suspected peripheral bone infection.11 The guideline11 recommends laboratory tests of C-reactive protein, erythrocyte sedimentation rate, and white blood cell count be performed in patients with suspected peripheral bone infection for diagnosis purposes (Level of evidence: 4). The guideline recommends conventional X-ray radiography to be used as first imaging modality for diagnosis and follow-up of suspected peripheral bone infection (Level of evidence: 3). Once peripheral bone infection is diagnosed by clinical and radiological means, bone biopsy is the reference standard to confirm the infection and should be conducted to identify the microorganism causing the infection (Level of evidence: 4). In complex anatomic areas, CT is recommended as an adjunct imaging modality to the conventional radiographs to detect bone sequestra (Level of evidence: 4). The guideline acknowledges that non-contrast MRI has high diagnostic performance (Level of evidence: 2), three-phase bone scintigraphy is sensitive, but not highly specific (Level of evidence: 2), and white blood cell scintigraphy and antigranulocyte antibody scintigraphy have similar diagnostic accuracy (Level of evidence: 2) in diagnosis of peripheral bone infection. The guideline also acknowledges that PET has high diagnostic accuracy in diagnosis of peripheral bone infection without fracture and osteosynthesis (Level of evidence: 2). No specific recommendations were provided for these diagnostic modalities. The guideline suggests that the use of hybrid SPECT-CT imaging can improve the detection of exact localization of infection (Level of evidence: 2). When hematogenous spread of the infection is suspected, the guideline recommends PET/CT to be used as the first imaging modality (Level of evidence: 5).
The UMHS guideline12 provided recommendations specific to patients with diabetic foot infection. It recommends bone biopsy and bone culture for suspected osteomyelitis in diabetic foot infections (Strength of recommendation: I; Level of evidence: C). For imaging tests, the guideline recommends that X-ray radiography is used firstly to evaluate suspected non-superficial soft tissue infection or osteomyelitis (Strength of recommendation: I; Level of evidence: C). With suspected soft tissue abscess, MRI is recommended as the next imaging test (Strength of recommendation: II; Level of evidence: E). In case if negative or equivocal radiograph of suspected osteomyelitis, or if there is a need to evaluate the extent of osteomyelitis on positive radiograph, the guideline recommends MRI as the next imaging test (Strength of recommendation: I; Level of evidence: C). If MRI is not available, the guideline recommends the use of triple-phase bone scan in combination with tagged white blood cell scan (Strength of recommendation: I; Level of evidence: C).
The IDSA guideline13 provided recommendations specific to patients with suspected native vertebral osteomyelitis. It recommends a medical and neurological examination, as well as laboratory tests including bacterial (aerobic and anaerobic) blood cultures, baseline erythrocyte sedimentation rate and C-reactive protein in patients with suspected native vertebral osteomyelitis (Strong recommendation; Low-quality evidence). The guideline recommends spine MRI in patients with suspected native vertebral osteomyelitis (Strong recommendation; Low-quality evidence). When MRI is not available or cannot be obtained in patients having implantable cardiac devices, cochlear implants, or claustrophobia, the guideline suggests the use of a combination of spine gallium/Tc99 bone scan, or a CT scan, or a PET scan (Weak recommendation; Low-quality evidence). In patients with subacute native vertebral osteomyelitis who are living in endemic area for brucellosis, the guideline recommends performing blood cultures and serologic tests for Brucella species (Strong recommendation; Low-quality evidence). Performing fungal blood cultures is suggested in patients with suspected native vertebral osteomyelitis and at risk of fungal infection (Weak recommendation; Low-quality evidence). In patients with subacute native vertebral osteomyelitis and at risk of Mycobacterium tuberculosis, the guideline suggests conducting a purified protein derivative test or obtaining an interferon-ɣ release assay (Weak recommendation; Low-quality evidence).
Limitations
There was a lack of evidence regarding the diagnostic accuracy of serial X-rays (i.e., initial assessment with X-rays followed by subsequent X-rays in 1 to 3 weeks) in adults with suspected osteomyelitis. Similarly, there was a lack of evidence regarding the clinical utility and cost-effectiveness of serial X-ray radiography for the detection of osteomyelitis in adults.
Conclusions and Implications for Decision or Policy Making
This review included three evidence-based guidelines for diagnosis of peripheral bone infection,11 diabetic foot infection12 and native vertebral osteomyelitis13 in adults.
The included guidelines had recommendations for diagnosis of osteomyelitis at different body parts (i.e., peripheral bone infection,11 diabetic foot infection12 and native vertebral osteomyelitis13), regarding medical examinations, laboratory tests, bone biopsies and bone cultures, and imaging tests. Two guidelines11,12 recommend X-ray radiography to be used as first-line imaging modality for the diagnosis of osteomyelitis in peripheral bone infection or in diabetic foot infection. One guideline13 recommends spine MRI in patients with suspected native vertebral osteomyelitis, without mentioning anything about radiography. Bone biopsy and bone culture are considered as the reference standard to confirm the infection and identify the causative microorganism.11–13 All three guidelines11–13 had recommendations for the use other imaging modalities including MRI, CT, PET, SPECT, scintigraphy depending on the extent of the investigation, the availability of the imaging modalities, the level of diagnostic accuracy required, the complexity of the disease, and patients’ contraindication.
Overall, despite MRI, PET and SPECT having been found to have higher diagnostic performance than radiography, it is recommended that conventional X-ray radiography should be the first imaging modality for detection of osteomyelitis, particularly in peripheral bone infection or in diabetic foot infection. With suspected native vertebral osteomyelitis, spine MRI, when feasible, is recommended as first imaging choice for diagnosis.
There is a need for studies examining the diagnostic accuracy, clinical utility and cost-effectiveness of serial X-ray radiography for detection of osteomyelitis in adults.
References
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Pediatr Radiol. 2011;41: Suppl 1:S127–134. [
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TJ. Diagnosis and management of osteomyelitis.
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MJ, et al. ACR appropriateness criteria((R)) suspected osteomyelitis, septic arthritis, or soft tissue infection (excluding spine and diabetic foot).
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PubMed: 28473089]
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PubMed: 28366223]
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JT, et al. Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection.
Emerg Radiol. 2018;25(2):175–188. [
PubMed: 29058098]
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A, Altman
DG, Tetzlaff
J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
J Clin Epidemiol. 2009;62(10):e1–e34. [
PubMed: 19631507]
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Glaudemans
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PC, Cataldo
MA, et al. Consensus document for the diagnosis of peripheral bone infection in adults: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement).
Eur J Nucl Med Mol Imaging. 2019;46(4):957–970. [
PMC free article: PMC6450853] [
PubMed: 30675635]
- 12.
Mills
JP, Patel
P, Broekhuizen
E, et al. Michigan Medicine Clinical Care Guidelines.
Diabetic foot infections. Ann Arbor (MI): Michigan Medicine University of Michigan; 2019. [
PubMed: 31967768]
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Berbari
EF, Kanj
SS, Kowalski
TJ, et al. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults.
Clin Infect Dis. 2015;61(6):e26–46. [
PubMed: 26229122]
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Appendix 1. Selection of Included Studies
Appendix 2. Characteristics of Included Studies
Table 2Characteristics of Included Guidelines
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| First Author, Society/Group Name, Publication Year, Country, Funding | Intended Users and Target Population | Intervention and Practice Considered | Major Outcomes Considered | Evidence Collection, Selection and Synthesis | Recommendations Development and Evaluation | Guideline Validation |
|---|
EANM, EBJIS, ESR, and ESCMID, Glaudemans et al., 201911 Europe Funding: Unclear | Intended users: Healthcare professionals Target population: Adult patients with a suspicion of peripheral bone infection (PBI) | Diagnostic management of adult patients with PBI. Diagnostic imaging modalities considered included radiography, CT, MRI, PET, SPECT and scintigraphy | All outcomes related to diagnosis of PBI (clinical assessment, symptoms, sings, laboratory parameters, bone biopsy, radiological and nuclear medicine imaging methods) | Systematic methods were used to search for evidence, selection and synthesis | The guideline was developed by members from four European societies, who defined clinical questions to be addressed, reviewed the literature and evaluated the diagnostic accuracy of each diagnostic technique. Each consensus statement was followed by a level of evidencea created by the Oxford Centre for Evidence-Based Medicine 201114 | The guideline was peer-reviewed |
UMHS, Mills et al., 201912 USA Funding: No financial support | Intended users: All healthcare professionals involving in the care of patients with diabetic foot infection (DFI) Target population: Adult patients with DFI | Diagnostic management of adult patients with DFI. Diagnostic imaging modalities considered included radiography, MRI, and scintigraphy | All outcomes related to diagnosis, imaging and treatment of DFI | Systematic methods were used to search for evidence, selection and synthesis | The guideline was developed by team members who are experts in the field of DFI. The strength of recommendationsb were graded based on the level of evidencec | The guideline was peer-reviewed |
IDSA, Berbari et al., 201513 USA Funding: IDSA | Intended users: Infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO) Target population: Adult patients with NVO | Diagnosis and treatment of NVO in adults. Diagnostic imaging modalities considered included MRI, gallium/Tc99 bone scan, CT, and PET | All outcomes related to diagnosis, and management of NVO | Systematic methods were used to search for evidence, selection and synthesis | The guideline was developed by an expert panel. The strength of recommendation and quality of evidence were systematically weighted using GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.d | The guideline was peer-reviewed |
CT = computed tomography; DFI = diabetic foot infection; EANM = European Association of Nuclear Medicine; EBJIS = European Bone and Joint Infection Society; ESCMID = European Society of Microbiology and Infectious Disease; ESR = European Society of Radiology; IDSA = Infectious Diseases Society of America; MRI = magnetic resonance imaging; NVO = native vertebral osteomyelitis; PBI = peripheral bone infection; PET = positron emission tomography; SPECT = single-photon emission computed tomography; UMHS = University of Michigan Health System.
- a
Level of evidence
Level 1: Systematic review of randomized trials
Level 2: Randomized trial
Level 3: Non-randomized controlled cohort/follow-up study
Level 4: Case-series, case-control, or historical controlled studies
Level 5: Mechanism-based reasoning
- b
Strength of recommendation:
I = Generally should be performed
II = May be reasonable to perform
III = Generally should not be performed
- c
Level of evidence:
A = systematic review of randomized controlled trials with or without meta-analysis
B = randomized controlled trials
C = systematic review of non-randomized controlled trials or observational studies, non-randomized controlled trials, group observational studies (cohort, cross-sectional, case-control)
D = individual observational studies (case study/case series)
E = expert opinion regarding benefits and harm
- d
Details of the strength of recommendations, quality of evidence, clarity of balance between desirable and undesirable effects, and implications are presented in the published guideline.13 The recommendations were graded from strong to weak, while the quality of evidence was assessed as high quality to very low quality. The strength of recommendation and the quality of the evidence were presented together based on the clarity of balance between desirable and undesirable effects, the methodological quality of supporting evidence and implications of recommendations.
Appendix 3. Quality Assessment of Included Studies
Table 3Quality Assessment of Guidelines
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| AGREE II checklist9 | EANM, EBJIS, ESR, and ESCMID, Glaudema ns et al., 201911 | UMHS, Mills et al., 201912 | IDSA, Berbari et al., 201513 |
|---|
| Scope and purpose | — | — | — |
| 1. Objectives and target patient population were explicit | Yes | Yes | Yes |
| 2. The health question covered by the guidelines is specifically described | Yes | Yes | Yes |
| 3. The population to whom the guidelines is meant to apply is specifically described | Yes | Yes | Yes |
| Stakeholder involvement | — | — | — |
| 4. The guideline development group includes individuals from all relevant professional groups | Yes | Yes | Yes |
| 5. The views and preferences of the target population have been sought | Yes | Yes | Yes |
| 6. The target users of the guideline are clearly defined | Yes | Yes | Yes |
| Rigour of development | — | — | — |
| 7. Systematic methods were used to search for evidence | Yes | Yes | Yes |
| 8. The criteria for selecting the evidence are clearly described | Yes | Yes | Yes |
| 9. The strengths and limitations of the body of evidence are clearly described | Yes | Yes | Yes |
| 10. The methods of formulating the recommendations are clearly described | Yes | Yes | Yes |
| 11. The health benefits, side effects, and risks have been considered in formulating the recommendations | Yes | Yes | Yes |
| 12. There is an explicit link between the recommendations and the supporting evidence | Yes | Yes | Yes |
| 13. The guideline has been externally reviewed by experts prior to its publication | Yes | Yes | Yes |
| 14. A procedure for updating the guideline is provided | Yes | Yes | Unclear |
| Clarity of presentation | — | — | — |
| 15. The recommendations are specific and unambiguous | Yes | Yes | Yes |
| 16. The different options for management of the condition or health issue are clearly presented | Yes | Yes | Yes |
| 17. Key recommendations are easily identified | Yes | Yes | Yes |
| Applicability | — | — | — |
| 18. The guideline describes facilitators and barriers to its application | Yes | Yes | Yes |
| 19. The guidelines provides advice and/or tools on how the recommendations can be put into practice | Yes | Yes | Yes |
| 20. The potential resource (cost) implications of applying the recommendations have been considered | Yes | Yes | Yes |
| 21. The guideline presents monitoring and/or auditing criteria | Yes | Yes | Yes |
| Editorial independence | — | — | — |
| 22. The views of the funding body have not influenced the content of the guideline | Unclear | Unclear | Unclear |
| 23. Competing interests of guideline development group members have been recorded and addressed | Yes | Yes | Yes |
EANM = European Association of Nuclear Medicine; EBJIS = European Bone and Joint Infection Society; ESR = European Society of Radiology; ESCMID = European Society of Microbiology and Infectious Disease; IDSA = Infectious Diseases Society of America; UMHS = University of Michigan Health System.
Appendix 5. Additional References of Potential Interest
About the Series
CADTH Rapid Response Report: Summary with Critical Appraisal
Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.
Suggested citation:
Serial X-Ray Radiography for the Diagnosis of Osteomyelitis: A Review of Diagnostic Accuracy, Clinical Utility, Cost Effectiveness, and Guidelines. Ottawa: CADTH; 2020 Mar. (CADTH rapid response report: summary with critical appraisal).
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