DIABETICMedicine

DOI: 10.1111/dme.12750

Invited Review
Challenges in diagnosing infection in the diabetic foot
A. W. J. M. Glaudemans1, I. Uckay2,3 and B. A. Lipsky2,4
1
Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands, 2Service
of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland, 3Orthopaedic Surgery Service, Geneva University Hospitals and
Faculty of Medicine, Geneva, Switzerland and 4Division of Medical Sciences, University of Oxford, Oxford, UK

Accepted 10 March 2015

Abstract
Diagnosing the presence of infection in the foot of a patient with diabetes can sometimes be a difficult task. Because open
wounds are always colonized with microorganisms, most agree that infection should be diagnosed by the presence of
systemic or local signs of inflammation. Determining whether or not infection is present in bone can be especially
difficult. Diagnosis begins with a history and physical examination in which both classic and secondary findings
suggesting invasion of microorganisms or a host response are sought. Serological tests may be helpful, especially
measurement of the erythrocyte sedimentation rate in osteomyelitis, but all (including bone biomarkers and
procalcitonin) are relatively non-specific. Cultures of properly obtained soft tissue and bone specimens can diagnose
and define the causative pathogens in diabetic foot infections. Newer molecular microbial techniques, which may not
only identify more organisms but also virulence factors and antibiotic resistance, look very promising. Imaging tests
generally begin with plain X-rays; when these are inconclusive or when more detail of bone or soft tissue abnormalities is
required, more advanced studies are needed. Among these, magnetic resonance imaging is generally superior to standard
radionuclide studies, but newer hybrid imaging techniques (single-photon emission computed tomography/computed
tomography, positron emission tomography/computed tomography and positron emission tomography/magnetic
resonance imaging) look to be useful techniques, and new radiopharmaceuticals are on the horizon. In some cases,
ultrasonography, photographic and thermographic methods may also be diagnostically useful. Improved methods
developed and tested over the past decade have clearly increased our accuracy in diagnosing diabetic foot infections.
Diabet. Med. 32, 748759 (2015)

Introduction
As the incidence of diabetes mellitus increases worldwide and
people with this disease live longer, the number of patients
developing a diabetic foot complication is growing dramatically. The most common foot problem is an ulceration,
which is most often related to the consequences of prolonged
peripheral neuropathy, often in association with peripheral
arterial disease. While all foot wounds require treatment,
those that are infected are at the highest and most urgent risk
of dire consequences, including lower extremity amputation
and occasionally infection-related death [1]. They are also
the only foot wounds that require antimicrobial therapy.
Thus, diagnosing infection is key to proper treatment of
diabetic foot wounds.
How, then, should we define infection of the diabetic foot?
Many clinicians might respond, I know it when I see it, but
infection appears to be mostly in the eye of the beholder.
Infections are generally defined in one of two ways: 1) the
Correspondence to: Benjamin A. Lipsky. E-mail: dblipsky@hotmail.com

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laboratory isolation of pathogenic microorganisms from a

normally sterile site (e.g. blood, cerebral spinal fluid, sterilely
collected deep tissue) or 2) a constellation of clinical signs
and symptoms compatible with an infectious syndrome. The
classic clinical manifestations of infection, dating from
antiquity, are: erythema (rubor), warmth (calor), swelling
(tumor), pain or tenderness (dolor). There are two major
problems with diagnosing diabetic foot infections. First, all
open wounds are colonized with microorganisms, making
culture results diagnostically non-definitive. Second, the
presence of peripheral neuropathy and vascular disease can
either diminish or mimic inflammatory findings, both in the
soft tissue and underlying bones, reducing their usefulness.
At presentation for medical care, about half of these wounds
are clinically infected [2,3].

Clinical presentation and probe-to-bone

testing
Clinical evaluation (see Table 1) begins with the patients
history. Patients with diabetic foot infections will typically

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Table 1 Summary of potentially useful clinical findings in diagnosing

diabetic foot infection
A. History
1. Long duration ( > 4 weeks) of foot wound
2. Previous infection at the same or a nearby site
3. Presence of new pain in the wound (especially in a
previously insensate foot)
4. Presence of immunosuppressive condition (beyond that
related to diabetes)
B. Physical examination
1. Large wound ( > 2 cm2)
2. Deep wound ( > 3 mm)
3. Classic signs of inflammation (tenderness, pain, redness,
warmth, induration)
4. Secondary signs of infection (foul odour, friable or
discoloured granulation tissue, rim undermining,
purulent or non-purulent secretions)

have a history of a current or recent (although occasionally

forgotten) wound that caused a break in the protective skin
envelope. These may be caused by mechanical, chemical or
thermal trauma, but are most often attributable to pressure
on a neuropathic (deformed and insensate) foot. On physical
examination, infections are more likely to be present in
wounds that are chronic (present for > 2 weeks), large
( > 2 cm2) or deep ( > 3 mm). Other than cases of erysipelas/cellulitis or surgical site infections, infection in the
diabetic foot is an epiphenomenon of underlying problems
related to various concomitant comorbidities. Most important among these are peripheral neuropathy (affecting
sensory, motor and autonomic nerves) and peripheral arterial
disease. These disorders can either lead to a diminution of the
expected inflammatory response or be the cause of these signs
and symptoms [4]. The great majority of patients with a
diabetic foot infection have peripheral neuropathy affecting
the feet. In a sizeable percentage of them, Charcot neuroosteoarthropathy may be present. In the acute stages this can
manifest as a red, warm, painful foot, mimicking soft tissue
infection, while in the chronic phase it can lead to bony
abnormalities that may suggest osteomyelitis [5]. Similarly,
peripheral arterial disease, which is present in the majority of
patients with diabetic foot infections, may impair manifestations of erythema, warmth or induration, or cause pain
(claudication) or dependent rubor [6]; thus, seeking cardinal
or textbook signs of inflammation, such as warmth,
redness, pain/tenderness, swelling, or loss of function alone
may not be sufficient to diagnose infection. Clinicians must
often seek other potential manifestations of infection, such as
fever, shivering, or purulent secretions, and ask about any
spreading inflammation over the preceding hours or days
[7,8]. Because these findings are often lacking in diabetic foot
infection, some advocate defining infection of a wound by
the presence of secondary findings, such as foul odour,
serous exudate, undermining of the wound rim, discoloured
or friable granulation tissue [9].
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DIABETICMedicine

Based on the available evidence, the 2012 guidelines on

diabetic foot infections produced by both the Infectious
Diseases Society of America and the International Working
Group on the Diabetic Foot advocate defining infection as
the presence of at least two of the classic findings of
inflammation or purulence [10]. Because of the problems
discussed above, in situations where clinicians are uncertain
about whether or not infection is present, some advocate
empirical treatment with antibiotic agents for 2 or 3 days to
see if clinical signs or symptoms improve. We do not
condone this approach, as it is likely to lead to overtreatment
of uninfected wounds based on a misperceived belief that the
response is to antibiotic therapy. Because diabetic foot
wounds respond to standard wound care, such as cleansing,
debridement, appropriate dressings, pressure offloading and
improved glycaemic control, improvement may not actually
be related to antibiotic-induced killing of infecting pathogens. Our recommended approach in such a situation is to
optimize wound care and carefully observe the patient;
should more clear evidence of infection appear, cultures and
antibiotic treatment are then appropriate.
Diagnosing osteomyelitis of the diabetic foot is particularly
problematic. Patients with a history of foot wounds, or with
deep wounds (especially over bony prominences) are more
likely to develop infection of the underlying bone [2]. In
almost all cases, diabetic foot osteomyelitis occurs in a
patient who has a current or recent soft tissue wound
through which contiguous infection leads to bone involvement. Notably, bone infection can sometimes occur under
what appears to be a clinically uninfected ulcer [11]. The
presence of a sausage toe, a red, swollen, warm digit, is
typical of diabetic foot osteomyelitis. The only virtually
pathognomonic clinical sign of osteomyelitis, however, is the
presence of fragments of bone in the wound or dressing, or
fragments found during debridement. In contrast to long
bones, osteomyelitis of the diabetic toe often lacks a
sequestrum or sinus tract that can been easily distinguished
from an overlying ulcer [12].
The probe-to-bone test can be helpful in diagnosing
diabetic foot osteomyelitis, but only if it is performed and
interpreted correctly. The clinician should probe after debriding the wound, using a blunt metal (not wood or plastic)
probe; a characteristic feel of a hard, gritty surface constitutes a positive test [1]. The test is, however, not pathognomonic for bone infection. Indeed, based on several reports,
the sensitivity ranges from ~ 60 to 87%, the specificity from
85 to 91%, and the positive predictive value from 87 to
90%. The negative predictive value is only 5662% [1315].
Thus, a key issue in interpreting the test is the pretest
probability of osteomyelitis in the patient population being
studied. Where the clinical or imaging features make the
likelihood of osteomyelitis high, a positive test may be
sufficient for diagnosing probable osteomyelitis. By contrast,
where the suspicion of bone infection is low, a negative test is
helpful in ruling out the diagnosis. The test requires some

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experience to gain mastery and the interobserver concordance is relatively low, with a j index of ~ 50% [16]. On its
own, the performance characteristics of the probe-to-bone
test are similar to those of other less regarded variables, such
as an ulcer area > 2 cm2 or an erythrocyte sedimentation
rate of > 70 mm/h [17].

Serum inflammatory markers

As with other local infections, serum inflammatory markers
are frequently not elevated in diabetic foot infections, especially in chronic cases. As the available literature reports
conflicting performance characteristic results, recommendations on the relative usefulness of the several available tests
vary. Some have found higher baseline levels of C-reactive
protein, erythrocyte sedimentation rate and white blood cell
levels in osteomyelitis cases than in those of soft-tissue
infections [18]. While serological tests cannot be used alone,
and the recommended thresholds for differentiating these two
vary, most consider an erythrocyte sedimentation rate
of > 6070 to be perhaps the most suggestive of osteomyelitis
[19]. The serum procalcitonin level is one of the newer tests
promulgated for diagnosing infections. Only a few studies
have reported results in patients with skin and soft tissue
infections; these have found that procalcitonin correlates with
disease classification (being more often elevated in complicated than uncomplicated infections), clinical course of
infection, and other laboratory markers of inflammation
[20]. Results in patients with diabetic foot infections, especially osteomyelitis, have generally been disappointing [21
23]. Levels are higher in infected than in uninfected diabetic
foot ulcers, but the performance characteristics are not as good
as the erythrocyte sedimentation rate or C-reactive protein
levels [24]. Our review of the available studies suggests that, in
the absence of systemic manifestations of localized infection,
procalcitonin does not help to distinguish acute infection from
acute ischaemia or other non-infectious conditions, or to
differentiate soft-tissue infection from osteomyelitis.
Investigators have sought other serum markers that may
help diagnose infection, especially osteomyelitis. One such
marker is bone sialoprotein because Staphylococcus aureus
isolates from patients with osteomyelitis express bone
sialoprotein-binding protein that binds the corresponding
bone matrix protein. In one pilot study of patients with a
diabetic foot ulcer, serological assays for bone sialoproteinbinding protein discriminated cases of osteomyelitis from
those with just soft tissue infections [25]. Another innovative
approach could be the measurement of bone turnover
markers, which might indirectly help with the diagnosis
and monitoring of patients with osteomyelitis. Bone alkaline
phosphatase and serum amino-terminal telopeptides are two
such markers; however, in a recent study analysing their
performance in 54 patients with diabetes, neither marker was
useful in detecting osteomyelitis, either at baseline or followup, nor did they help predict outcome [26]. One new idea is

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to investigate the value of measuring local cytokine titres in

patients with osteomyelitis. A preliminary retrospective study
of immunohistochemical staining of bone biopsy specimens
of patients with diabetic foot osteomyeltis showed that stains
for interleukin-6 were intensively positive in cases with acute
infection while stains for tumour necrosis factor-a were
positive in chronic or reparative states [27]. Further studies
are needed to see if these markers may prove useful as, for
example, interleukin-6 expression is also high in the acute
Charcot foot [28].

Histopathology
In some cases osteomyelitis can only be diagnosed by
examining a specimen of bone, obtained either at the time
of surgery or by percutaneous biopsy. Most believe the
criterion standard for diagnosing bone infection is obtaining
positive results on both culture and histopathological examination of bone. This is because bone cultures can be falsely
negative if a patient is taking antibiotics and falsely positive
because of contamination of the specimen, while histopathology can be falsely negative if the infected area is missed
or inaccurate when read by an inexperienced pathologist.
Unfortunately, cultures of soft tissue, even deep aspiration
near the infected bone, do not provide sufficiently accurate
results compared with bone specimens. Even needle bone
puncture appears to provide significantly fewer positive
results (58%) compared with transcutaneous bone biopsy
(97%) [29]. A recent study has shown that when bone
cultures are negative, subsequent occurrence of osteomyelitis
within 2 years follow-up is infrequent [30].
Bone specimens from patients with long-standing diabetes
may be found to have myelofibrosis, osteonecrosis and
osteoporosis at affected sites, but are usually normal or
unremarkable when the bone is not infected [31]. Thus, the
presence in bone of inflammatory cells (particularly polymorphonuclear leukocytes, but also mononuclear cells) and
the presence of necrosis indicate bone infection, especially if
microorganisms are visible microscopically and there is no
other reason for chronic inflammation. The criteria for
histopathological diagnosis of osteomyelitis, however, have
not been validated or standardized. The findings of a recent
study showed a remarkable lack of agreement among
pathologists who independently reviewed 39 consecutive
diabetic foot bone biopsy specimens blinded to the patients
clinical characteristics [32]. In only one-third of cases was
there complete agreement on the presence or absence of
osteomyelitis and in 41% of cases there was a clinically
important disagreement between at least two of the pathologists. This distressing result may have been at least partly
related to the absence of an agreed-upon classification
scheme for diabetic foot osteomyelitis. In light of this finding
and based on extensive experience, Cecilia-Matilla et al. [33]
proposed a well defined scheme of four histopathological
types of diabetic foot osteomyelitis according to the cell

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groups present and the histopathological changes in the bone

samples: acute osteomyelitis; chronic osteomyelitis; acute
chronic osteomyelitis; and fibrosis stage (an unresolved final
process of bone infection with fibrotic, avascular tissue).
Using this scheme they showed much less intra-observer
variability between two pathologists [34]. One member of
this group developed a clinical classification scheme for types
of osteomyelitis: without ischaemia or soft tissue involvement (class 1); with ischaemia but without soft tissue
involvement (class 2); with soft tissue involvement (class 3);
and with ischaemia and soft tissue involvement (class 4).
Applying these criteria in a study of 48 patients showed that
the classes were associated with a statistically significant
trend among the four types toward increased severity,
amputation rates and mortality [35]. Other groups will need
to test these classification schemes and it remains to be seen if
they gain wider acceptance.

Culture
Although detecting microorganisms within a diabetic foot
wound (see Table 2) does not currently define the presence of
infection, it is a necessary step for selecting the optimum
therapeutic approach. For over 150 years, we have used
methods developed by Pasteur and others to detect and
classify pathogens. These methods have been useful, but are
limited by several problems. Firstly, we only grow the
organisms we know how to look for, and these easy-to-grow
species may actually be laboratory weeds and we may be
missing true pathogens that standard techniques fail to
identify. Secondly, cultivating microorganisms and determining their sensitivity patterns usually takes at least 2
3 days, even with the newer more rapid techniques. During
this waiting period we are forced to treat the patient with an
empiric antibiotic regimen, which has been shown to be
inappropriate in almost a quarter of cases [36]. With the
growing pandemic of antibiotic resistance pathogens this
problem is likely to worsen, and it has major clinical and
financial consequences [37]. Thirdly, with over a third of
diabetic foot infections being polymicrobial, we cannot
currently determine which of the microorganisms are truly

playing a pathogenic role and which are merely colonizers.

Fourthly, standard culture methods lead to false-negative
results in patients who are already being treated with
antimicrobial agents, a common clinical situation. Finally,
we have learned that bacteria in wounds are commonly
found in biofilms, making them more difficult to culture (as
well as to treat) [38]. So, how do we address these problems?
To start, while we still depend on the microbiology
laboratory, clinicians need to properly collect and quickly
send them optimum specimens. Although taking a swab of a
wound is easy and inexpensive, it clearly provides a
suboptimum specimen, giving culture results that are both
less sensitive and less specific than with a tissue specimen
[39]. This is clearly a situation where garbage in (a poorly
obtained wound specimen, especially when it takes hours to
get to the laboratory) leads to garbage out (an unhelpful
laboratory report such as mixed cutaneous flora or no S.
aureus found). Quantitative microbiology, championed by
some over the past 50 years, is not the answer, both because
it has not been shown to prove a wound is infected and
because non-research clinical laboratories do not provide this
complex and expensive service.
The future of microbiology certainly appears to be the
newer molecular technologies that are currently making their
way into many diagnostic laboratories. These techniques will
allow rapid identification (probably in less than an hour) of
all of the microorganisms in a wound. Furthermore, they will
rapidly report on the presence of genes that code for
pathogenicity and for resistance to commonly used antibiotic
agents. If this sounds like a distant dream, or an episode of
Crime Scene Investigation, it is not [40]. Newer molecular
tools allow detection of the > 500 species of microorganisms
that constitute the microbiota on various colonized surfaces,
including the skin. Remarkable progress in sequencing
bacterial genomes and the development of new molecular
approaches has facilitated an understanding of the steps in
the evolution of the complex flora of skin microbiota as well
as the development of wound infection.
We now recognize that bacteria within a diabetic foot
wound are often in biofilms, i.e. composites of aggregated
cells encased in an extracellular matrix of hydrated polymers

Table 2 Comparison of methods for identifying causative pathogens in diabetic foot infections
Type of processing

Major advantages

Major disadvantages

When to order

Other comments

Standard culture

Widely available
Relatively inexpensive

If only method available

Unusual organisms unlikely

Can be supplemented by
Gram-stained smear

Molecular
diagnostic
methods

More sensitive
Identifies wider range
of organisms
More rapid

Only identifies known

pathogens
Results depend on type of
specimen collected and rules
regarding reporting
Not widely available yet
More expensive
Uncertainty about how to
interpret results

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Diabetic Medicine 2015 Diabetes UK

Unusual organisms more likely

Severe infection
Patient on antibiotic therapy
Rapid identification important

May also provide

information on the
presence of genes
coding for virulence
factors and antibiotic
resistance

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and debris, which impair wound healing and protect the

enmeshed bacteria from host immune responses and antimicrobials. This has led to the concept of microorganisms in
a wound behaving as functionally equivalent pathogroups,
in which species that usually behave in a non-pathogenic
manner on their own may co-aggregate to act synergistically
to cause a chronic infection. Molecular methods have
uniformly shown that most diabetic foot ulcers host many
more bacterial species in greater numbers than previously
appreciated. Available data suggest that diabetic foot
infections more often arise from the presence of specific
combinations of pathogens than a simple increase in the
microbial load of any one opportunistic microbe. Furthermore, compared with the superficial flora, those from the
deep tissue are more complex and diverse, and especially
rich in anaerobic species. Investigations in the diabetic foot
have shown that the enrichment of the number of S. aureus
organisms may be a precursor to developing clinically
apparent infection in a diabetic foot ulcer. Microbiota
studies have also shown that certain wound flora are
associated with several specific clinical characteristics of
the diabetic foot, including ulcer depth (a surrogate for
wound severity) and duration (which may be a surrogate for
delayed wound healing) [41].
Studies examining the role of S. aureus, the predominant
pathogen in diabetic foot infection, have highlighted the coexistence of several populations, and that a combination of
five specific genes may help distinguish colonized from
infected wounds and predict ulcer outcome, which contributes to more appropriate use of antibiotics [42]. Studies have
also shown that using oligonucleotide arrays to determine the
type of clonal complex of S. aureus isolates by DNA arrays is
a promising technique for distinguishing uninfected from
infected wounds, predicting ulcer outcome and thereby
contributing to more appropriate use of antibiotics [43].
Metagenomic approaches have vastly increased our knowledge on the genomes, activity and functionality of the
complex ecosystem residing within the diabetic foot ulcer.

Imaging techniques
The role of imaging in managing the infected diabetic foot
(see Table 3) is expanding and now often plays a key role in
both diagnosis and successful treatment. The aims of all
existing imaging techniques include helping to either exclude
an infection or to confirm the diagnosis, to evaluate the
extent of an existing infection, and to differentiate among
bone infection (osteomyelitis), soft tissue infection and
neuro-osteoarthropathy (Charcot foot). Unfortunately, there
is no single imaging technique that can routinely and
accurately provide all of this information. Key concerns are
that some imaging tests are insensitive when used for an early
diagnosis of the disease, while others are non-specific, as they
cannot easily differentiate between bony changes related to
neuro-osteoarthropathy vs. infection.

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Radiological imaging techniques

Plain X-ray

Plain radiography of the foot, taken in at least two different

projections, should virtually always be the initial imaging test
[44,45]. It is inexpensive, widely available, and can detect
major bone structural changes as well as tissue gas and foreign
bodies. Characteristic changes in the early phase of osteomyelitis are focal lucency, loss of trabecular pattern and cortical
destruction; later abnormalities include periosteal reaction,
sclerosis and new bone formation [45]. Overall, the sensitivity
( ~ 60%) and the specificity ( ~ 80%) of plain radiography in
diagnosing osteomyelitis in the infected diabetic foot are
relatively low [5]. This relates to three major limitations: 1)
bony changes are only visible when there is demineralization
of > 3050% of the bone, which usually takes at least 2
4 weeks; 2) radiography is suboptimal for detecting soft tissue
infection, although some non-specific signs (induration,
obliteration of peri-articular fat planes) may be seen; and, 3)
differentiating infection from neuro-osteoarthropathy, which
may sometimes co-exist, is difficult. It is possible to overcome
some of these limitations by performing serial radiographs
(e.g. every 2 weeks), which may be useful in detecting changes
that are characteristic of osteomyelitis over time [10]. For
many patients in whom the likelihood of osteomyelitis is
either very high or low, the results of plain radiographs may
be sufficient to confirm the clinical suspicion.
Magnetic resonance imaging

When plain radiography fails to provide a clear answer about

the involvement of bone in a diabetic foot, advanced imaging is
usually needed. Magnetic resonance imaging (MRI) is widely
considered the best available radiological imaging technique
currently available to detect the presence and extent of bone
and soft tissue involvement. It is useful, when available and not
contraindicated, to identify the extent of the involved soft
tissue and bone, provide information on vascular perfusion (by
different MRI perfusion sequences, such as arterial spin
labelling and dynamic susceptibility contrast imaging) and
may help guide surgical options [46,47]. When osteomyelitis is
present MRI of affected bone shows a decreased bone marrow
signal on T1-weighted sequences, and increased signal intensity on T2-weighted images. A finding of increased T2 signal
and normal T1 signal represents oedema suggestive of soft
tissue infection [47]. Administering i.v. gadolinium aids
evaluation of soft tissue involvement and may help demonstrate abscesses, synovitis, deep tissue necrosis and sinus tracts
[47,48] and to differentiate cellulitis (which enhances with
gadolinium) from non-infectious oedema (with no enhancement) [49]; however, as gadolinium is relatively contraindicated in patients with renal impairment, which is found in
many patients with diabetic foot infection, its use to enhance
MRI is limited in these patients. For the diagnosis of diabetic
foot osteomyelitis MRI has an overall sensitivity of ~ 90%
and a specificity ~ 80% [45].
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Relatively inexpensive
Widely available
Can detect major bone
structural changes, tissue gas
and foreign bodies
Able to identify extent of
involved soft tissue and bone
Provides information on
vascular perfusion
May help guide surgical options
No radiation exposure

Good imaging of soft tissue fluid

col-lection, joint effusion,
foreign bodies, bone cortex
To guide aspirations or biopsies
Widely available
Long experience
SPECT/CT increases diagnostic
accuracy

Plain X-rays

CT

Short acquisition time

High image resolution
Avoids need for blood
manipulation
Low physiological background
uptake
Absolute simultaneous match
between tissue information of
both techniques
Better localization of PET signal
No radiation exposure with MRI

FDG-PET/CT

Sensitivity 29100%
Specificity 6793%

Not available

8001200

10001500

Expensive
Limited availability
Long acquisition time
Limited published experience

To rule out infection when

suspicion is low; otherwise
only a secondary technique

Sensitivity ~ 90%
Specificity ~ 50%

300400

Increased uptake in inflammation

and malignancy, as well as
infection
No consensus criteria for
interpretation

Only when other better

advanced imaging
techniques are not available

Sensitivity ~ 80%
Specificity ~ 70%

300400

Although a positive bone

scan is as likely to be a falseas a true-positive, a negative
scan largely rules out an
infection
Flow-chart for correct
acquisition and
interpretation results in
higher diagnostic accuracy
Leads to better localization
of site and extent of
infection
Need consensus criteria on
when to declare a scan
positive or negative and how
to differentiate between
infection, inflammation and
osteoarthropathy
Has the potential to become
the premier advanced
imaging techniqueideal
one-stop shopping approach

Not recommended by
diabetic foot infection
guidelines

Extensively studied and

widely considered the best
available imaging technique

Serial repeat radiographs

could overcome several
limitations by detecting
changes over time

Other comments

F-fluorodeoxyglucose-positron emission tomography. WBC:

18

Consider when degree of

clinical suspicion and MRI/
radiographic findings are
incongruent or when MRI is
contraindicated or not
available *
Unknown

Consider when degree of

clinical suspicion and MRI/
radiographic findings are
incongruent or when MRI is
contraindicated or not
available *

In patients who require

additional imaging when
soft tissue involvement is
suspected or diagnosis
remains uncertain after
preliminary evaluations

Sensitivity ~ 90%
Specificity ~ 80%

500800

Sensitivity 72100%
Specificity 67100%

Should usually be the first

imaging test ordered

Sensitivity ~ 60%
Specificity ~ 80%

100200

600800

When to order

Sensitivity/
specificity

Relative
costs ()

Requires laborious preparation

under sterile conditions
Associated with risk to patient
and technicians from handling
potentially infectious blood

Bone changes only visible when

demineralization > 3050%;
Suboptimal for detecting soft
tissue infection, differentiating
infection from osteoarthropathy
Cannot always differentiate
infection from osteoarthropathy
Often limited availability
Requires skilled radiologist
Cannot image patients who
have various types of implanted
devices or who have
claustrophobia
Soft tissue contrast lower than
with MRI
Difficult to demarcate healthy
from infected tissue
Low specificity because of
increased uptake in any cause of
increased bone formation

Major disadvantages

MRI, magnetic resonance imaging; CT, computed tomography; SPECT, single-photon emission computed tomography; FDG-PET,
white blood cells
*
No consensus within the nuclear medicine community on which nuclear technique is the procedure of choice.

PET/MRI

Specific for leukocytic infiltration

Results not affected by
antibiotic treatment
Accurately detects both acute
and chronic infections

WBC scan +
SPECT/CT

Bone scan
+ SPECT/CT

MRI

Major advantages

Imaging test

Table 3 Types of imaging tests for diabetic foot infections

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Challenges in diagnosing infection in the diabetic foot  Glaudemans et al.

The major limitation of MRI is that it cannot always

reliably differentiate between infection and neuro-osteoarthropathy. Findings supporting neuro-osteoarthropathy are
the presence of intra-articular bodies or subchondral cysts and
involvement of multiple joints, while findings suggesting
osteomyelitis are diffuse signal enhancement in an entire bone,
replacement of fat adjacent to abnormal bone and the
presence of a concurrent skin ulcer or a sinus tract [50].
Differentiating these two conditions is especially problematic
when an infectious process is superimposed on a Charcot foot,
when a patient has had a recent surgical intervention in the
foot, or when osteosynthesis material is present at the site of
interest. Other potential limitations of MRI are its limited
availability in many locations, high costs, the need for a skilled
specialist radiologist and its inability to image patients with
various types of implanted devices (e.g. orthopaedic metalwork, pacemaker, surgical clips) or who have claustrophobia.
Ultrasonography/computed tomography

Diagnostic ultrasonography and computed tomography (CT)

each play a limited role in the evaluation of diabetic foot
disorders and are not recommended in most published
diabetic foot guidelines [46,49,51,52]. If other and better
techniques are not available, ultrasonography may be used to
detect the presence of soft tissue fluid collections, joint
effusion and foreign bodies [49] and to guide peri-articular
aspirations or soft tissue biopsies [53]. CT is more accurate
than plain radiography for evaluation of cortical erosions,
focal areas of lucency, bone sequestra [45] and soft tissue
gas. Compared with MRI, however, the soft tissue contrast is
lower and it is more difficult to demarcate between healthy
and infected tissue.

Nuclear medicine imaging techniques

Nuclear medicine techniques detect in vivo pathophysiological changes, sometimes even before anatomical changes are
observable. The role of nuclear medicine techniques for
imaging infectious diseases has been enhanced by new
insights into methods to acquire and interpret standard
imaging techniques, recent developments in integrated camera systems that combine physiological and anatomical data
and the availability of more specific tracers.
Bone scintigraphy

Three-phase bone scintigraphy was among the first, and

remains the most widely used, nuclear imaging procedure for
the diagnosis of musculoskeletal infections. This technique
has a high sensitivity (i.e. when all three phases are negative
infection is highly unlikely) but unfortunately a low specificity (i.e. many false-positive results). Any cause of increased
bone formation (e.g. recent surgery, fractures, malignancy,
metabolic bone disease, prosthetic loosening) may cause
increased uptake of diphosphonates in the late (third) phase.
Furthermore, in several of these conditions there may also be

754

increased blood flow (first phase) or blood pool (second

phase). Meta-analyses of the use of three-phase bone
scintigraphy for detection of diabetic foot infection using
only planar imaging, or combined with single-photon emission computed tomography (SPECT), estimate a sensitivity
of ~ 90% but a specificity of ~ 50% [45,48,54]. Although
recent development in camera systems (SPECT/CT) may lead
to better diagnostic accuracy, the many causes of high
diphosphonate uptake make this technique a secondary
imaging technique for diagnosing diabetic foot infection. Its
main usefulness is that a negative scan largely rules out an
infection, although scintigraphy may be falsely negative in
patients with lower extremity ischaemia.
Labelled white blood cells

The use of radiolabelled white blood cells (WBC) is still

considered the best nuclear imaging technique for musculoskeletal infections. Labelling with 99mTechnetium is preferred
to 111Indium as it has better radiation characteristics, requires
a lower radiation dose, has higher image resolution and lower
costs. This technique is quite specific for detecting leukocytic
infiltration, its results are not affected by recent or current
antibiotic treatment [55,56] and it can accurately detect both
acute and chronic (even low grade) infections. The disadvantages of WBC scintigraphy include the fact that its preparation
is laborious, it must be performed under sterile conditions, it
takes a trained technician ~ 3 h to do the labelling and it
exposes the patient to a relatively high dose of radiation. In
addition, the tests requirement for handling potentially
infectious blood puts both technicians and patients at risk.
The role of radiolabelled WBCs in diabetic foot infections
has been extensively investigated, with reported sensitivities of
72100% and specificities of 67100% [48,54,57,58]. The
poorer results are generally reported from studies using only
planar imaging with poor spatial resolution and no bony
landmarks to help differentiate soft tissue infection from
osteomyelitis. The reasons for the variability in reported
diagnostic accuracies include variations in labelling procedures, acquisition protocols and interpretation criteria [59,60].
Recently, data from two studies led to a proposal for a new
flow chart for the correct acquisition and interpretation of
WBC scintigraphy including dual-time point imaging (34 h
and 2024 h after administration) with time decay-corrected
acquisition [55,61]. Over time, an increase in WBC uptake
strongly supports an infection, whereas a decrease in uptake
makes infection highly unlikely. In doubtful or equivocal
cases, performing a semi-quantitative analysis using the
contralateral side as reference may be useful. Following this
flowchart results in high diagnostic accuracy; its implementation in new guidelines developed by the Infection and
Inflammation Committee of the European Association of
Nuclear Medicine should lead to better and more comparable study results at different centres.
In the past decades, some suggested that the combining of
bone scans with WBC scintigraphy, or bone scan/WBC

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scintigraphy and bone marrow imaging, might improve

diagnostic accuracy. Unfortunately, studies found that using
these techniques together did not substantially improve the
results [59,62]. We believe that when nuclear medicine
specialists use the correct protocol for WBC imaging and
interpretation there is no need for additional bone and/or
bone marrow imaging.
Single-photon emission computed tomography/computed
tomography

Using new integrated camera systems that combine physiological and anatomical data has now become standard
procedure. SPECT/CT has several advantages over standard
or dual isotope scans: it can provide excellent cortical spatial
resolution, is less expensive than dual scintigraphy, delivers a
lower radiation dose, and can be used with several different
isotope agents. In WBC scintigraphy adding SPECT/CT to
the early images (34 h) leads to better localization of the site
and the extent of the infection, and better differentiation
between soft tissue infection and osteomyelitis [61], thereby
achieving better diagnostic accuracy [63]. Using a composite
severity index (a standardized hybrid image-based scoring
system) appears to add prognostic value for diagnosing
diabetic foot osteomyelitis to 99mTc-SPECT/CT [64].
Another additional potential use of SPECT/CT is helping to
determine when diabetic foot osteomyelitis has resolved.
This is a key issue for knowing when to discontinue
antibiotic therapy and whether or not surgical treatment
may be needed, yet it is probably even more difficult than
diagnosing infection. One study with 29 patients with
diabetic foot osteomyelitis found that a negative WBC
SPECT/CT at the end of antibiotic therapy had a 100%
negative predictive value (and 71.5% positive predictive
value) for detecting relapse of infection [65].
18

F-fluorodeoxyglucose positron emission tomography

The newer technology of positron emission tomography

(PET) with 18F-fluorodeoxyglucose (FDG) has several theoretical advantages over standard scintigraphy: it avoids the
need for blood manipulation (like WBC scintigraphy); acquisition time is shorter; image resolution is higher; and
physiological FDG background uptake is low. The major
limitation of this technique is that, in addition to infection,
FDG accumulates in malignancies and inflammation, because
cells involved in all three of these processes metabolize glucose
as a source of energy [66]. Increased glucose metabolism of
leucocytes, macrophages, monocytes, lymphocytes and giant
cells occurs in infectious and inflammatory diseases, but
uptake is also seen in regenerating and traumatic processes.
The FDG-PET method may be helpful in the diagnosis of
diabetic foot infection, but its role in the evaluation of
diabetic foot infection has yet to be clarified [67]. Diagnostic
accuracies have varied from 54 to 94% [6871]. A recent
systematic review and meta-analysis found nine studies
comprising 299 patients evaluated for diabetic foot prob-

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lems. The quantitative analysis of four selected studies

provided the following results on a per patient-based
analysis: sensitivity 74%; specificity 91%; positive likelihood
ratio 5.56; negative likelihood ratio 0.37; and diagnostic
odds ratio 17 [72]. What is now needed is a consensus about
which criteria should be used to declare the results of a scan
as positive or negative and how best to differentiate between
infectious and non-infectious entities. For now, when FDGPET imaging shows no increased uptake infection is unlikely,
but when FDG uptake is increased, it is challenging to
differentiate between the various causes: infection, inflammation, neuro-osteoarthropathy, recent surgery, fractures,
osteophytes, enthesopathy and degenerative changes. Currently, PET camera systems are combined with CT to allow
precise anatomical localization of the FDG uptake (Fig. 1).
This facilitates differentiation between osteomyelitis and soft
tissue infection, but does not solve the problem of differentiating among infection, inflammation and osteoarthropathy.
Notably, elevated blood glucose levels negatively influence
the accuracy of FDG-PET scans; obviously, this is a common
finding in patients with suspicion of an infected diabetic foot.
Other nuclear tracers
67

Gallium (67 Ga)-citrate.

67

Ga-citrate was previously used

extensively for imaging infections but its suboptimum
intrinsic characteristics (poor spatial resolution, non-specific
binding) and the development of better tracers have resulted
in it rarely being used currently. In a recent study of 67GaSPECT/CT with 55 patients with suspected diabetic foot
osteomyelitis it had a negative predictive value of 100%, but
a positive predictive value of only 50% [73].
Antigranulocyte antibodies. Considerable efforts have been
devoted to developing in vivo methods for WBC labelling
that could overcome the limitations of in vitro-labelled
WBCs. Although production of antigranulocyte monoclonal
antibodies (e.g. Scintimun, LeukoScan) has been promising, the results have not been found to be better than in vitro
99m
Tc-labelled WBCs.
Labelled WBCs for PET imaging. WBCs have also been
labelled in vitro with FDG in an attempt to develop a more
specific PET tracer. Only a few published studies are
available on this tracer (none of which included patients
with an infected diabetic foot) and results have varied
[59,74]. Unfortunately, this technique delivers high amounts
of radioactivity and, because of the short half-life of 18F
(110 min), it is technically not feasible to perform imaging > 45 h after injection.

Which imaging technique is the first choice?

Both the Infectious Disease Society of America and the

International Working Group on the Diabetic Foot have

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DIABETICMedicine

(a)

(b)

(c)

(d)

FIGURE 1 Example of 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/ computed tomography (CT) imaging in a patient with
diabetes with suspicion of an infected foot. (a) sagittal PET view. (b) Sagittal PET/CT fusion. (c) Transversal PET view. (d) Transversal PET/CT
fusion. Note increased FDG uptake most compatible with osteomyelitis involving the plantar aspect of the fifth metatarsus and infection in the
adjacent soft tissues (Figure provided courtesy of Dr Zohar Keidar, Ramban Health Care Campus, Haifa, Israel).

included recommendations in their guidelines for imaging

diabetic foot infections. Recently, a promising combined
diagnostic flow chart was proposed by a committee of
expert clinicians, radiologists and nuclear medicine specialists [56]. Plain radiography is recommended in all
patients who present with a potential diabetic foot
infection, to look for bony as well as soft tissue abnormalities [1]. If both the clinical presentation and X-rays
are most compatible with osteomyelitis, no further diagnostic evaluation is needed. For patients in whom either
the diagnosis or the optimum surgical approach is unclear,
additional imaging with MRI is recommended [1]. Nuclear
medicine imaging techniques should be considered in cases
in which clinical suspicion and MRI/radiographic findings
are incongruent or inconclusive, or when MRI is contraindicated or not available. There is no general consensus
within the nuclear medicine community on which nuclear
technique should be the procedure of choice, but most
would recommend either labelled WBCs with SPECT/
CT or FDG-PET/CT. Large-scale studies, preferably
comparing these techniques with MRI, are needed to
determine the most appropriate imaging tool and to
analyse the cost-effectiveness of all available imaging
techniques.

756

Future perspectives in imaging

Positron emission tomography/magnetic resonance imaging

Simultaneous imaging with the recently developed combined

PET/MRI camera system has the potential to become the
premier technique for assessing the infected diabetic foot. It
combines acquisition and quantification of functional data at
the molecular level with superior soft tissue resolution and
anatomical detail. Advantages include providing an absolute
match between the tissue information of both techniques
under the same physiological conditions (PET/CT is performed sequentially, not simultaneously), better localization
of the PET signal within soft tissues, no radiation exposure
with MRI, and a one-stop-shopping approach for the patient
by allowing the acquisition of diagnostic quality imaging
results of nuclear medicine and radiological techniques in one
visit. This hybrid PET/MRI imaging could optimally differentiate among soft tissue infection, osteomyelitis, inflammation and neuropathic osteoarthropathy [75].
Possible new positron emission tomography
radiopharmaceuticals

In most clinical situations, and particularly in the low grade

infected diabetic foot, imaging at late time points (e.g. 24 h

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after injection) is necessary because of the slow leukocyte

accumulation in infected sites as compared with bone
marrow. Regrettably, this delay between injection and
imaging is not possible using 18F as radiolabel, but fortunately, 64Copper, with a half-life of 12.7 h, appears to be a
more suitable radionuclide for labelling of white blood cells;
the first attempts to in vitro labelling of WBCs with 64Copper
have been successful [76], and we are anxiously waiting for
the first clinical results.
68
Ga-citrate PET/CT imaging is another emerging technology. The imaging characteristics of the PET tracer 68Ga
are superior to those of 67Ga because it provides higher
spatial resolution and because of the quantification potential
of PET. 68Ga-citrate has other advantages, including rapid
blood clearance, quick diffusion and the fact that it can be
produced in any hospital by generator without the need of a
cyclotron on site; however, to date there has been only one
study in 31 patients with suspected osteomyelitis (showing a
diagnostic accuracy of 90%) and there is no experience in
patients with infected diabetic foot [77].
Tailored radiopharmaceuticals

Advances in molecular techniques and translational medicine

have taken nuclear medicine to the threshold of a new
diagnostic era. Personalized medicine, based on individual
characteristics of the patient and the pathogen, is now under
investigation in large oncological trials and has the potential
to provide optimum treatment in infectious diseases. Nuclear
medicine techniques provide the opportunity to characterize
pathophysiological processes histologically, highlight the cell
type(s) involved, detect the presence of a potential target,
quantify the pathogenic bacteria and biologically active
molecules (e.g. cytokines and chemokines) and detect the
presence of apoptopic and autoreactive cells [78]. It may also
allow evidence-based biological therapy by assessing which
molecule will localize in an infected area, then using the same
unlabelled molecule therapeutically [78].

Photographic foot imaging and infrared thermography

Patients at risk of foot ulcers should be screened regularly by

an appropriately trained healthcare professional. In some
situations, however, this rather time-consuming, relatively
intrusive and costly procedure may not be logistically
possible. In those situations, using telemedicine diagnostic
support in the home environment may allow the required
foot assessment. Recently, investigators developed a photographic foot imaging device to use for home monitoring for
the early diagnosis of foot ulcers and pre-ulcerative lesions in
patients with diabetes [79]. The device provided high-quality
digital photographs of the plantar foot surface that could be
remotely assessed by a foot specialist.
As infections tend to cause inflammation and increased
blood flow, increased skin temperature is another important
sign of possible foot infection. Home monitoring of foot

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temperatures by infrared thermometry has been shown to be

effective in patients with diabetes [80]. In fact, infrared
thermal cameras may be useful to either detect infections or
to predict which patients are at risk of future foot complications [81], including infections [82]. In a recent study of 38
patients with a diabetic foot complication assessed with
photographic and temperature sensing devices, diagnosis of
infection from photographs was specific ( > 85%) but not
very sensitive ( < 60%), while thermography was sensitive
( > 90%) but not very specific ( < 25%). Diagnosis based on
the combination of both techniques was both sensitive
( > 60%) and specific ( > 79%) with good intra-observer
agreement [83]. These techniques are promising for the home
monitoring of high-risk patients with diabetes to facilitate
early diagnosis of signs of infection [83].

Conclusions
In the past decade we have made great strides in diagnosing
infection in the diabetic foot. Clinical examination (history,
physical, probe-to-bone) remains the first and most important
diagnostic approach. Laboratory tests, especially the erythrocyte sedimentation rate, but disappointingly not procalcitonin,
provide some help, especially with diagnosing and following
osteomyelitis, but we need better tests. The coming availability
of molecular microbiology in clinical laboratories will almost
certainly help to not only more rapidly identify causative
pathogens, but also to provide information on their potential
virulence. Advanced imaging techniques, particularly hybrid
imaging possibilities (SPECT/CT and PET/MRI) have made
these tests more useful in both diagnosing infection and
helping to direct therapy. Our clinical forbears would be
jealous of our diagnostic armamentarium, but our students
seem poised to benefit from the next generation of the new
techniques that are now emerging.

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