Preview

Variant: 1 Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.

Procedure	Appropriateness Category
Radiography chest	Usually Appropriate
CT chest with IV contrast	May Be Appropriate
CT chest without IV contrast	May Be Appropriate
MRI chest without and with IV contrast	Usually Not Appropriate
MRI chest without IV contrast	Usually Not Appropriate
CT chest without and with IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 2 Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.

Procedure	Appropriateness Category
CT chest with IV contrast	Usually Appropriate
CT chest without IV contrast	Usually Appropriate
MRI chest without and with IV contrast	Usually Not Appropriate
MRI chest without IV contrast	Usually Not Appropriate
CT chest without and with IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 3 Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.

Procedure	Appropriateness Category
CT abdomen and pelvis with IV contrast	Usually Appropriate
US abdomen	May Be Appropriate
CT abdomen and pelvis without IV contrast	May Be Appropriate (Disagreement)
Radiography abdomen	Usually Not Appropriate
Fluoroscopy contrast enema	Usually Not Appropriate
Fluoroscopy upper GI series with small bowel follow-through	Usually Not Appropriate
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate
Nuclear medicine scan gallbladder	Usually Not Appropriate
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate
WBC scan abdomen and pelvis	Usually Not Appropriate

Variant: 4 Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.

Procedure	Appropriateness Category
Radiography chest	Usually Appropriate
US abdomen	May Be Appropriate
CT abdomen and pelvis with IV contrast	May Be Appropriate
CT chest with IV contrast	May Be Appropriate
CT chest without IV contrast	May Be Appropriate
CT chest abdomen pelvis with IV contrast	May Be Appropriate
CT chest abdomen pelvis without IV contrast	May Be Appropriate (Disagreement)
Radiography abdomen	Usually Not Appropriate
Fluoroscopy contrast enema	Usually Not Appropriate
Fluoroscopy upper GI series with small bowel follow-through	Usually Not Appropriate
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate
MRI chest without and with IV contrast	Usually Not Appropriate
MRI chest without IV contrast	Usually Not Appropriate
Nuclear medicine scan gallbladder	Usually Not Appropriate
CT abdomen and pelvis without IV contrast	Usually Not Appropriate
CT chest without and with IV contrast	Usually Not Appropriate
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate
WBC scan abdomen and pelvis	Usually Not Appropriate

Variant: 5 Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Normal or equivocal or nonspecific chest radiograph. Next imaging study.

Procedure	Appropriateness Category
CT abdomen and pelvis with IV contrast	Usually Appropriate
US abdomen	May Be Appropriate
CT abdomen and pelvis without IV contrast	May Be Appropriate (Disagreement)
CT chest with IV contrast	May Be Appropriate
CT chest without IV contrast	May Be Appropriate
CT chest abdomen pelvis with IV contrast	May Be Appropriate (Disagreement)
CT chest abdomen pelvis without IV contrast	May Be Appropriate (Disagreement)
Radiography abdomen	Usually Not Appropriate
Fluoroscopy contrast enema	Usually Not Appropriate
Fluoroscopy upper GI series with small bowel follow-through	Usually Not Appropriate
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate
MRI chest without and with IV contrast	Usually Not Appropriate
MRI chest without IV contrast	Usually Not Appropriate
Nuclear medicine scan gallbladder	Usually Not Appropriate
CT chest without and with IV contrast	Usually Not Appropriate
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate
WBC scan abdomen and pelvis	Usually Not Appropriate

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please visit https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

1. [26903338] 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.
2. [31954465] 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.
3. [23442987] 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.
4. [24199255] 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.
5. [23984731] Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013;369:840-51.
6. [32971451] 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.
7. [25468363] 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.
8. [21215552] 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.
9. [23776621] 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.
10. [22176803] 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.
11. [30788532] 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.
12. [33827655] Pijl JP, Londema M, Kwee TC, et al. FDG-PET/CT in intensive care patients with bloodstream infection. Crit Care 2021;25:133.
13. [6600545] 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.
14. [32072724] 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.
15. [26754121] 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.
16. [11307365] Llewelyn M, Cohen J, International Sepsis F. Diagnosis of infection in sepsis. Intensive Care Med 2001;27 Suppl 1:S10-32.
17. [26441019] Pages-Bouic E, Millet I, Curros-Doyon F, Faget C, Fontaine M, Taourel P. Acute pelvic pain in females in septic and aseptic contexts. Diagnostic and Interventional Imaging. 96(10):985-95, 2015 Oct.Diagn Interv Imaging. 96(10):985-95, 2015 Oct.
18. [23422051] 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.
19. [-3196415] 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.
20. [8583440] 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.
21. [2112472] 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.
22. [16404232] 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.
23. [-3128692] American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination