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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 315(8):801-10, 2016 Feb 23. Review/Other-Dx 19 patients To evaluate and, as needed, update definitions for sepsis and septic shock. Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. 4
2. Rudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet 2020;395:200-11. Review/Other-Dx 109 million To estimated the global, regional, and national incidence of sepsis and mortality from this disorder using data from GBD 2017 In 2017, an estimated 48·9 million (95% uncertainty interval [UI] 38·9-62·9) incident cases of sepsis were recorded worldwide and 11·0 million (10·1-12·0) sepsis-related deaths were reported, representing 19·7% (18·2-21·4) of all global deaths. Age-standardised sepsis incidence fell by 37·0% (95% UI 11·8-54·5) and mortality decreased by 52·8% (47·7-57·5) from 1990 to 2017. Sepsis incidence and mortality varied substantially across regions, with the highest burden in sub-Saharan Africa, Oceania, south Asia, east Asia, and southeast Asia. 4
3. Gaieski DF, Edwards JM, Kallan MJ, Carr BG. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med 2013;41:1167-74. Review/Other-Dx N/A To describe the variations in incidence and mortality of severe sepsis in the United States using four methods of database abstraction.To hypothesize that different methodologies of capturing cases of severe sepsis would result in disparate estimates of incidence and mortality. The average annual incidence varied by as much as 3.5-fold depending on method used and ranged from 894,013 (300/100,000 population) to 3,110,630 (1,031/100,000) using the methods of Dombrovskiy et al and Wang et al, respectively. Average annual increase in the incidence of severe sepsis was similar (13.0% to 13.3%) across all methods. In-hospital mortality ranged from 14.7% to 29.9% using abstraction methods of Wang et al and Dombrovskiy et al. Using all methods, there was a decrease in in-hospital mortality across the 6-year period (35.2% to 25.6% [Dombrovskiy et al] and 17.8% to 12.1% [Wang et al]). Use of ICD-9 sepsis codes more than doubled over the 6-year period (158,722 - 489,632 [995.92 severe sepsis], 131,719 - 303,615 [785.52 septic shock]). 4
4. Torio CM, Andrews RM. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011: Statistical Brief #160. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD); 2006. Review/Other-Dx N/A To describes the distribution of costs by expected primary payer and illustrates the conditions accounting for the largest percentage of each payer’s hospital costs. No results stated in the abstract. 4
5. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013;369:840-51. Review/Other-Dx N/A To discuss severe sepsis and septic shock. No results stated in the abstract 4
6. Pohlan J, Witham D, Muench G, et al. Computed tomography for detection of septic foci: Retrospective analysis of patients presenting to the emergency department. Clin Imaging. 69:223-227, 2021 Jan. Observational-Dx 357 patients To determine the current role of computed tomography (CT) in the diagnostic workup of septic patients. Of 357 ED patients with suspected sepsis, 37.0% (132/357) underwent CT imaging within 72 h. The most commonly identified septic foci in CT were chest 38.6% (49/127), abdomen 22.0% (28/127) and genitourinary tract 20.5% (26/127) in descending order. The focus detection rate was 76.5% per patient with a concurrent number-needed-to-scan of 1.31. Contrast medium administration in CT did not improve focus detection rate (p = 0.631) or diagnostic confidence in this patient population (p = 0.432). CT had a positive predictive value of 81.82% (CI 76.31 to 86.28%) in predicting the focus of the discharge diagnosis. Follow-up imaging in patients with unclear focus reveals a new focus in 39.5% of patients. 2
7. Just KS, Defosse JM, Grensemann J, Wappler F, Sakka SG. Computed tomography for the identification of a potential infectious source in critically ill surgical patients. Journal of Critical Care. 30(2):386-9, 2015 Apr. Review/Other-Dx 76 studies To conduct a retrospective single-center analysis of CT and its therapeutic consequences in an operative intensive care unit in a tertiary care hospital in Germany. In 76 CT studies (52.8%), a source of infection was found and was associated with a change in treatment in 65 (85.5%) cases. In contrast, in patients without identification of an infectious source in the CT imaging, treatment was changed after CT imaging in 11 (16.2%) cases. Computed tomography provided positive findings predominantly in the organ or the region of the surgical field. 4
8. Capp R, Chang Y, Brown DF. Accuracy of microscopic urine analysis and chest radiography in patients with severe sepsis and septic shock. Journal of Emergency Medicine. 42(1):52-7, 2012 Jan. Observational-Dx 170 patients To evaluate the accuracy of two diagnostic studies used in the emergency department (ED) to guide diagnosis of source of infection in this patient population. Of the 1400 patients admitted to intensive care units, 170 patients met criteria for severe sepsis and septic shock. There were a total of 47 patients diagnosed with urinary tract infection, and their initial microscopic urine analysis with counts>10 white blood cells were 80% sensitive (95% confidence interval [CI] .66-.90) and 66% specific (95% CI .52-.77) for the positive final urine culture result. There were 85 patients with final diagnosis of pneumonia. The sensitivity and specificity of initial chest radiography were, respectively, 58% (95% CI .46-.68) and 91% (95% CI .81-.95) for the diagnosis of pneumonia. 2
9. Tseng JR, Chen KY, Lee MH, Huang CT, Wen YH, Yen TC. Potential usefulness of FDG PET/CT in patients with sepsis of unknown origin. PLoS ONE. 8(6):e66132, 2013. Observational-Dx 53 patients To assess the value of FDG PET/CT in patients with sepsis of unknown cause and to define its priority in this group of subjects. Of the 53 study patients, 35 (66%) had positive FDG PET/CT findings, and 13 (25%) had their treatment modified on the basis of the imaging results. Logistic regression analysis identified normal serum aspartate aminotransferase (odds ratio [OR] = 6.134; 95% confidence interval [CI] = 1.443-26.076, P = 0.014) and increased serum alkaline phosphatase levels (OR = 5.813; 95% CI = 1.386-24.376, P = 0.016) at diagnosis as independent predictors of positive FDG PET/CT findings. A scoring system using these two covariates was developed, which defined three distinct priority groups for FDG PET/CT imaging. 2
10. Kluge S, Braune S, Nierhaus A, et al. Diagnostic value of positron emission tomography combined with computed tomography for evaluating patients with septic shock of unknown origin. J Crit Care. 27(3):316.e1-7, 2012 Jun. Observational-Dx 18 patients To evaluate the diagnostic value of FDG-PET/CT in critically ill patients with septic shock of unknown origin. Eighteen patients underwent FDG-PET/CT. Microbiological tests (blood culture, urine, and respiratory secretions), chest x-rays, CT scans, and transesophageal echocardiography were performed on all patients before FDG-PET/CT scanning. Pathologic FDG accumulation could be demonstrated in 14 of 18 FDG-PET/CT scans. On a per-patient basis, 11 were "true positive," 3 were "false positive," 4 were true negative, and there were no false negatives. In 6 cases, the results of the PET/CT scan had direct therapeutic consequences (surgery, 2; pacemaker removal, 2; initiation of antibiotic therapy, 1; and prolonged antibiotic therapy, 1); 12 (66%) of the 18 patients survived to hospital discharge. 2
11. Brondserud MB, Pedersen C, Rosenvinge FS, Hoilund-Carlsen PF, Hess S. Clinical value of FDG-PET/CT in bacteremia of unknown origin with catalase-negative gram-positive cocci or Staphylococcus aureus. Eur J Nucl Med Mol Imaging 2019;46:1351-58. Observational-Dx 157 patients To investigate the ability of FDG/PET-CT to detect the site of infection and its clinical impact in bacteremia of unknown origin with catalase-negative Gram-positive cocci (excluding pneumococci and enterococci) or Staphylococcus aureus (BUOCSA). FDG-PET/CT detected sites of infection in 56.4% of cases and had high clinical impact in 47.3%. It was the first imaging modality to identify sites of infection in 41.1% bacteremia cases, led to change of antimicrobial therapy in 14.7%, and established a new diagnosis unrelated to bacteremia in 9.8%. Detection rate and clinical impact were not significantly influenced by duration of antimicrobial treatment preceding FDG-PET/CT, days from suspicion of bacteremia to FDG-PET/CT-scan, type of bacteremia, or cancer. 2
12. Pijl JP, Londema M, Kwee TC, et al. FDG-PET/CT in intensive care patients with bloodstream infection. Crit Care 2021;25:133. Observational-Dx 30 patients To evaluate the diagnostic yield of FDG-PET/CT in intensive care patients with bloodstream infection (BSI) . 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. 2
13. Hoddick W, Jeffrey RB, Goldberg HI, Federle MP, Laing FC. CT and sonography of severe renal and perirenal infections. AJR Am J Roentgenol 1983;140:517-20. Review/Other-Dx 12 patients To twelve patients with urosepsis and severe renal or perirenal infections. No results stated in the abstract. 4
14. Ashkar C, Britto M, Carne P, Cheung W, Mirbagheri N. Perianal sepsis in neutropaenic patients with haematological malignancies: the role of magnetic resonance imaging and surgery. ANZ J Surg. 90(9):1642-1646, 2020 09. Review/Other-Dx 19 patients To assess the role of magnetic resonance imaging (MRI) and surgery in neutropaenic patients with perianal sepsis. Nineteen neutropaenic patients with haematological malignancy were treated for perianal sepsis, eight (42%) patients were managed conservatively and 11 (58%) were managed surgically. Nine patients underwent MRI, which identified a collection in 88% of cases despite severe neutropaenia. In patients with a collection identified on MRI prior to surgery, 80% had a drainable collection confirmed intraoperatively. Post-operative complications included two cases of sepsis from a presumed perianal source and one death. A total of 82% of patients experienced symptom resolution after surgery compared to 88% of patients managed conservatively. 4
15. Dreger NM, Degener S, Ahmad-Nejad P, Wobker G, Roth S. Urosepsis--Etiology, Diagnosis, and Treatment. [Review]. Dtsch. Arztebl. int.. 112(49):837-47; quiz 848, 2015 Dec 04. Review/Other-Dx N/A To review pertinent articles and guidelines retrieved by a selective search in PubMed regarding Urosepsis Enterobacteria and Gram-positive organisms are the pathogens that most commonly cause urosepsis. The diagnosis can and must be made early on the basis of the typical clinical features, altered vital signs, and laboratory abnormalities, so that timely treatment can be initiated. 80% of cases are due to obstructive uropathy. The diagnostic evaluation includes physical examination, blood cultures, urinalysis, procalcitonin measurement, and ultrasonography. In one study, each additional hour of delay in the treatment of urosepsis with antibiotics was found to lower the survival rate by 7.6%. Antibiotics should be chosen in consideration of local resistance patterns and the expected pathogen spectrum. 4
16. Llewelyn M, Cohen J, International Sepsis F. Diagnosis of infection in sepsis. Intensive Care Med 2001;27 Suppl 1:S10-32. Review/Other-Dx N/A To discuss the diagnosis of infection in sepsis No results stated in the abstract. 4
17. Pages-Bouic E, Millet I, Curros-Doyon F, Faget C, Fontaine M, Taourel P. Acute pelvic pain in females in septic and aseptic contexts. Diagn Interv Imaging. 96(10):985-95, 2015 Oct. Review/Other-Dx N/A To discuss the acute pelvic pain in females in septic and aseptic contexts. No results stated in the abstract. 4
18. Sorensen SM, Schonheyder HC, Nielsen H. The role of imaging of the urinary tract in patients with urosepsis. Int J Infect Dis. 17(5):e299-303, 2013 May. Review/Other-Dx 115 patients To provide recommendations for imaging of patients with urosepsis in order to detect urological complications that need intervention, as well as conditions that predispose to renal infection. Major abnormalities were found in 37 out of 115 (32%) patients. The two most common major abnormalities were hydronephrosis (17%) and urolithiasis (6%). Predictors of a major abnormality were diabetes with complications and any of the following: renal disease, pre-existing urological abnormality, or nephrolithiasis. Gender, age, blood pressure, fever, malignant disease, liver disease, neurological disease, prostatic disease, chronic indwelling urinary catheter, C-reactive protein, and white blood cell count did not show a statistically significant association with major abnormalities. 4
19. Erba P, Lazzeri E, Perri M, et al. Added value of SPECT/CT for scintigraphic imaging of infection with autologous 99mTc-HMPAO-labelled leukocytes. Journal of Nuclear Medicine 2007;48:64P-64P. Review/Other-Dx N/A To discuss the added value of SPECT/CT for scintigraphic imaging of infection with autologous 99mTc-HMPAO-labelled leukocytes No results stated in the abstract. 4
20. Carter CR, McKillop JH, Gray HW, Stewart IS, Anderson JR. Indium-111 leucocyte scintigraphy and ultrasound scanning in the detection of intra-abdominal abscesses in patients without localizing signs. J R Coll Surg Edinb 1995;40:380-2. Review/Other-Dx 45 patients To review the clinical records of suspected intra-abdominal sepsis patients but without localizing abdominal signs. No results stated in the abstract. 4
21. Baba AA, McKillop JH, Cuthbert GF, Neilson W, Gray HW, Anderson JR. Indium 111 leucocyte scintigraphy in abdominal sepsis. Do the results affect management? Eur J Nucl Med. 1990;16(4-6):307-309. Observational-Dx 45 patients Retrospective review of patients presenting with suspected intra-abdominal sepsis to examine the value of 111In-autologous leucocyte scintigraphy. Sensitivity of 95%, specificity of 91%. 34 of those studies were felt to help patient management by either being positive or negative. 4
22. Uslu H, Varoglu E, Kadanali S, Yildirim M, Bayrakdar R, Kadanali A. 99mTc-HMPAO labelled leucocyte scintigraphy in the diagnosis of pelvic inflammatory disease. Nucl Med Commun 2006;27:179-83. Observational-Dx 15 women To evaluate the importance of scintigraphy using 99mTc-HMPAO labelled leucocytes in the early diagnosis of patients with pelvic inflammatory disease. Scintigraphy detected pelvic inflammatory disease in five of the patients. In three of them the disease was apparent on the scans taken at 0.5-1 h, and in the other two it was apparent at 3 h. There were no false negative results, and one false positive result. The scan accurately reflected the absence of pelvic inflammatory disease in nine patients showing non-pathological tracer uptake in the lower abdominal region. 2
23. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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