Introduction: To evaluate and position existing critical care scoring systems to predict the need for ICU (Intensive Care Unit) management for patients with Emphysematous Pyelonephritis (EPN). To also analyze if CT-imaging further enhances the predictive systems.
Methods: Analysis of prospectively maintained database of consecutive patients diagnosed clinico-radiologically with EPN from January 2011 to September 2020. Five scoring systems were evaluated for their predictive ability for the need for ICU management and mortality risk: National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), ‘quick’ Sequential Organ Failure Assessment score (qSOFA), Systemic Inflammatory Response Syndrome score (SIRS), and Sequential Organ Failure Assessment score (SOFA). CT images were graded and evaluated as stand-alone or added to the different predictive models. Receiver operating characteristic (ROC) curves were plotted for each critical care score and CT-grade using logistic regression, to obtain the area under curve (AUC) value for comparison of ICU admission predictability.
Results: 90 patients were diagnosed with EPN. Twenty-six patients required ICU management and nine patients died. The best scoring system to predict the need of early ICU management is NEWS (AUC 0.884). CT imaging does further improve, though not statistically significant, the predictive model of NEWS from 0.884 to 0.894.
Supplement Table 2: Comparison of ROC curves of the various scores.
Variable
p-value
NEWS vs qSOFA
0.0871
NEWS vs MEWS
0.941
NEWS vs SOFA
0.0506
NEWS vs SIRS
0.00149
Supplement Table 3: Comparison of ROC curves of various scores with combination of CT Grade.
Variable
p-value
NEWS + CT vs qSOFA + CT
0.212
NEWS + CT vs MEWS + CT
0.74
NEWS + CT vs SOFA + CT
0.156
NEWS + CT vs SIRS + CT
0.00924
Table 3A - B: Mortality rate correlation with the various scoring systems and CT Grade.
Score
Cut-off
Mortality (N)
qSOFA = 2
<2
2
= 2
7
MEWS = 4
< 4
1
= 4
8
NEWS = 5
<5
1
= 5
8
SOFA = 2
<2
1
= 2
8
SIRS = 2
<2
1
= 2
8
EPN Grade
N
Mortality (N)
?
14
0
?
35
2
? A
15
0
? B
14
6
?
12
1
Supplement Table 4: Comparison of the EPN CT Grades with clinical outcomes using Chi-square test.
EPN Grade
N
Non-ICU (%)
ICU (%)
p-value
?
14
12 (85.7)
2 (14.3)
0.004
?
35
29 (82.9)
6 (17.1)
? A
15
10 (66.7)
5 (33.3)
? B
14
4 (28.6)
10 (71.4)
?
12
9 (75.0)
3 (25.0)
Supplement Table 5: Area under the ROC curve, sensitivity, and specificity data of the CT grade.
Score
Cut-off
AUC
95%CI
p-value
Sensitivity
Specificity
PPV
NPV
CT grade
=3A
0.667
0.547 to 0.786
0.013
69.23%
64.1%
43.9%
83.7%
Conclusions: In patients with EPN, the NEWS scoring system predicts best the requirement of ICU care. It aids in triage of patients with EPN to appropriate early management and reduce mortality risk.
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