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. 2021 Apr 7;25(1):133.
doi: 10.1186/s13054-021-03557-x.

FDG-PET/CT in intensive care patients with bloodstream infection

Jordy P Pijl #  1 , Mark Londema #  2 , Thomas C Kwee  3 , Maarten W N Nijsten  2 , Riemer H J A Slart  3   4 , Rudi A J O Dierckx  3 , Peter H J van der Voort  2 , Andor W J M Glaudemans  3 , Janesh Pillay  2
Affiliations

FDG-PET/CT in intensive care patients with bloodstream infection

Jordy P Pijl et al. Crit Care. .

Abstract

Background: 2-Deoxy-2-[18F]fluoro-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) is an advanced imaging technique that can be used to examine the whole body for an infection focus in a single examination in patients with bloodstream infection (BSI) of unknown origin. However, literature on the use of this technique in intensive care patients is scarce. The purpose of this study was to evaluate the diagnostic yield of FDG-PET/CT in intensive care patients with BSI.

Methods: In this retrospective cohort study, all intensive care patients from our Dutch university medical center who had culture-proven BSI between 2010 and 2020 and underwent FDG-PET/CT to find the focus of infection were included. Diagnostic performance was calculated and logistic regression analysis was performed to evaluate the association between FDG-PET/CT outcome and C-reactive protein level (CRP), leukocyte count, duration of antibiotic treatment, duration of ICU stay, quality of FDG-PET/CT, and dependency on mechanical ventilation. In addition, the impact of FDG-PET/CT on clinical treatment was evaluated.

Results: 30 intensive care patients with BSI were included. In 21 patients, an infection focus was found on FDG-PET/CT which led to changes in clinical management in 14 patients. FDG-PET/CT achieved a sensitivity of 90.9% and specificity of 87.5% for identifying the focus of infection. Poor quality of the FDG-PET images significantly decreased the likelihood of finding an infection focus as compared to reasonable or good image quality (OR 0.16, P = 0.034). No other variables were significantly associated with FDG-PET/CT outcome. No adverse events during the FDG-PET/CT procedure were reported.

Conclusion: FDG-PET/CT has a high diagnostic yield for detecting the infection focus in patients with BSI admitted to intensive care. Poor PET image quality was significantly associated with a decreased likelihood of finding the infection focus in patients with BSI. This could be improved by adequate dietary preparation and cessation of intravenous glucose and glucose-regulating drugs. Recent advances in PET/CT technology enable higher image quality with shorter imaging time and may contribute to routinely performing FDG-PET/CT in intensive care patients with BSI of unknown origin.

Keywords: Bacteremia; Bloodstream infection; Candidemia; Fungemia; PET/CT; Sepsis.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow diagram of patient inclusion. Notes: A These four patients were scheduled for FDG-PET/CT during their ICU stay, but were transferred to another department shortly before FDG-PET/CT was performed
Fig. 2
Fig. 2
A 10-year-old girl known with acute lymphocytic leukemia was admitted to the hospital because of fatigue and general malaise. During admission, the patient also developed fever, for which blood cultures were taken and cefuroxime was started. Blood cultures were positive for Candida albicans. A thoracic X-ray showed small bilateral pulmonary consolidations (a, yellow arrows), and thoracic CT showed multifocal opacities as well (b, red arrows), supporting the diagnosis of pulmonary candidiasis. Voriconazole and caspofungin were started, and a venous access point of the patient was removed because of potential colonization. Despite antifungal treatment, the patient remained febrile, with a CRP level of 61 mg/L and leukocyte count of 23.6 × 109/L. FDG-PET/CT was performed to evaluate other potential foci of infection. Coronal maximum intensity projection FDG-PET showed multiple small subcutaneous and intramuscular FDG avid foci (C, green arrows), and diffuse high FDG uptake in the esophagus (c, dashed green rectangle), suggestive of generalized candidiasis. Small FDG avid pulmonary consolidations were also visible on fused FDG-PET/CT (D, white arrows) as well as high FDG uptake in the esophagus (d, dashed white rectangle), and small subcutaneous and intramuscular FDG avid foci (E, blue arrows). Intensive antifungal therapy was continued, and the patient slowly recovered. The patient was discharged from the hospital 6 weeks after FDG-PET/CT
Fig. 3
Fig. 3
A 61-year-old woman was admitted to the ICU with septic shock. Blood cultures were positive for Group A Streptococcus. Based on physical examination, the suspected focus of infection was the right elbow or right knee. Arthrotomy and washout were performed on both joints. A microbiologic culture of the synovial fluid of the right knee also showed Group A Streptococcus. Antibiotic treatment with ceftriaxone and clindamycin was started. Because the patient remained septic, only a minor amount of pus was drained from the right knee, and CRP and leukocyte count remained high at 450 mg/L and 13 × 109/L, respectively, FDG-PET/CT was performed to identify another potential infection focus or to see if there was spread of infection. Fused coronal FDG-PET/CT (a), and coronal maximum intensity projection FDG-PET (b) showed increased FDG uptake in the right knee suggestive of arthritis (a, white arrow, b, orange arrow). By mistake, intravenous clindamycin infusion dissolved in 5% glucose and a continuous intravenous infusion with saline and 5% glucose solution were not stopped before FDG-PET/CT, resulting in increased FDG uptake of skeletal muscle (a dashed white rectangle, b dashed orange rectangle). Axial CT showed mild suprapatellar recess effusion (c, orange arrow). This was also visible on fused axial FDG-PET/CT (d, orange arrow), in addition to high intercondylar FDG uptake. No other evident infection focus was found on FDG-PET/CT, but the result was not conclusive due to high background uptake caused by inadequate patient preparation. Nevertheless, the patient slowly recovered and was discharged to a rehabilitation center three weeks after FDG-PET/CT
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