Mortality Risk for Acute Cholangitis (MAC): a risk prediction model for in-hospital mortality in patients with acute cholangitis

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Abstract

Background

Acute cholangitis is a life-threatening bacterial infection of the biliary tract. Main focus of this study was to create a useful risk prediction model that helps physicians to assign patients with acute cholangitis into different management groups.

Methods

981 cholangitis episodes from 810 patients were analysed retrospectively at a German tertiary center.

Results

Out of eleven investigated statistical models fit to 22 predictors, the Random Forest model achieved the best (cross-)validated performance to predict mortality. The receiver operating characteristics (ROC) curve revealed a mean area under the curve (AUC) of 91.5 %. Dependent on the calculated mortality risk, we propose to stratify patients with acute cholangitis into a high and low risk group. The mean sensitivity, specificity, positive and negative predictive value of the corresponding optimal cutpoint were 82.9 %, 85.1 %, 19.0 % and 99.3 %, respectively. All of these results emerge from nested (cross-)validation and are supposed to reflect the model’s performance expected for external data. An implementation of our risk prediction model including the specific treatment recommendations adopted from the Tokyo guidelines is available on http://www2.imse.med.tum.de:3838/.

Conclusion

Our risk prediction model for mortality appears promising to stratify patients with acute cholangitis into different management groups. Additional validation of its performance should be provided by further prospective trails.

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Most cited references 18

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Molecular epidemiology of Escherichia coli producing CTX-M beta-lactamases: the worldwide emergence of clone ST131 O25:H4.

Gisele Peirano, Johann D.D. Pitout (2010)

Since 2000, Escherichia coli producing CTX-M enzymes have emerged worldwide as important causes of community-onset urinary tract and bloodstream infections owing to extended-spectrum beta-lactamase (ESBL)-producing bacteria. Molecular epidemiological studies suggested that the sudden worldwide increase of CTX-M-15-producing E. coli was mainly due to a single clone (ST131) and that foreign travel to high-risk areas, such as the Indian subcontinent, might in part play a role in the spread of this clone across different continents. Empirical antibiotic coverage for these resistant organisms should be considered in community patients presenting with sepsis involving the urinary tract, especially if the patient recently travelled to a high-risk area. If this emerging public health threat is ignored, it is possible that the medical community may be forced, in the near future, to use carbapenems as the first choice for the empirical treatment of serious infections associated with urinary tract infections originating from the community. (c) 2009 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

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TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos).

Seiki Kiriyama, Tadahiro Takada, Steven M. Strasberg … (2013)

Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. However, it has been found that there are crucial limitations in these criteria. The diagnostic criteria of TG07 do not have enough sensitivity and specificity, and its severity assessment criteria are unsuitable for clinical use. A working team for the revision of TG07 was organized in June, 2010, and these criteria have been updated through clinical implementation and its assessment by means of multi-center analysis. The diagnostic criteria of acute cholangitis have been revised as criteria to establish the diagnosis where cholestasis and inflammation demonstrated by clinical signs or blood test in addition to biliary manifestations demonstrated by imaging are present. The diagnostic criteria of the updated Tokyo Guidelines (TG13) have high sensitivity (87.6 %) and high specificity (77.7 %). TG13 has better diagnostic capacity than TG07. Severity assessment is classified as follows: Grade III: associated with organ failure; Grade II: early biliary drainage should be conducted; Grade1: others. As for the severity assessment criteria of TG07, separating Grade II and Grade I at the time of diagnosis was impossible, so they were unsuitable for clinical practice. Therefore, the severity assessment criteria of TG13 have been revised so as not to lose the timing of biliary drainage or treatment for etiology. Based on evidence, five predictive factors for poor prognosis in acute cholangitis--hyperbilirubinemia, high fever, leukocytosis, elderly patient and hypoalbuminemia--have been extracted. Grade II can be diagnosed if two of these five factors are present. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

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New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo guidelines

Masamichi Yokoe, Tadahiro Takada, Steven M. Strasberg … (2012)

Background The Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were published in 2007 as the world’s first guidelines for acute cholangitis and cholecystitis. The diagnostic criteria and severity assessment of acute cholecystitis have since been widely used all over the world. A validation study of TG07 has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. In addition, considerable new evidence referring to acute cholecystitis as well as evaluations of TG07 have been published. Consequently, we organized the Tokyo Guidelines Revision Committee to evaluate TG07, recognize new evidence, and conduct a multi-center analysis to revise the guidelines (TG13). Methods and materials We retrospectively analyzed 451 patients with acute cholecystitis from multiple tertiary care centers in Japan. All 451 patients were first evaluated using the criteria in TG07. The “gold standard” for acute cholecystitis in this study was a diagnosis by pathology. The validity of TG07 diagnostic criteria was investigated by comparing clinical with pathological diagnosis. Results Of 451 patients evaluated, a total of 227 patients were given a diagnosis of acute cholecystitis by pathological examination (prevalence 50.3 %). TG07 criteria provided a definite diagnosis of acute cholecystitis in 224 patients. The sensitivity of TG07 diagnostic criteria for acute cholecystitis was 92.1 %, and the specificity was 93.3 %. Based on the preliminary results, new diagnostic criteria for acute cholecystitis were proposed. Using the new criteria, the sensitivity of definite diagnosis was 91.2 %, and the specificity was 96.9 %. The accuracy rate was improved from 92.7 to 94.0 %. In regard to severity grading among 227 patients, 111 patients were classified as Mild (Grade I), 104 as Moderate (Grade II), and 12 as Severe (Grade III). Conclusion The proposed new diagnostic criteria achieved better performance than the diagnostic criteria in TG07. Therefore, the proposed criteria have been adopted as new diagnostic criteria for acute cholecystitis and are referred to as the 2013 Tokyo Guidelines (TG13). Regarding severity assessment, no new evidence was found to suggest that the criteria in TG07 needed major adjustment. As a result, TG07 severity assessment criteria have been adopted in TG13 with minor changes.

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Author and article information

Contributors

Jochen Schneider: jochen.schneider@tum.de

Alexander Hapfelmeier: alexander.hapfelmeier@tum.de

Sieglinde Thöres: sieglinde.thoeres@tum.de

Andreas Obermeier: andreas.obermeier@tum.de

Christoph Schulz: christoph.schulz@tum.de

Dominik Pförringer: dominik.pfoerringer@tum.de

Simon Nennstiel: simon.nennstiel@tum.de

Christoph Spinner: christoph.spinner@tum.de

Roland M. Schmid: roland.schmid@tum.de

Hana Algül: hana.alguel@tum.de

Wolfgang Huber: wolfgang.huber@tum.de

Andreas Weber: 49-89-4140-5843 , andreas.weber@mri.tum.de

Journal

Journal ID (nlm-ta): BMC Gastroenterol

Journal ID (iso-abbrev): BMC Gastroenterol

Title: BMC Gastroenterology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-230X

Publication date (Electronic): 9 February 2016

Publication date PMC-release: 9 February 2016

Publication date Collection: 2016

Volume: 16

Electronic Location Identifier: 15

Affiliations

[ ]II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany

[ ]Institute of Medical Statistics and Epidemiology, Technische Universität München, München, Germany

[ ]Klinik für Orthopädie, Labor für Infektionsforschung, Klinikum rechts der Isar, Technische Universität München, München, Germany

[ ]Institut für klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, München, Germany

[ ]I. Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany

Article

Publisher ID: 428

DOI: 10.1186/s12876-016-0428-1

PMC ID: 4746925

PubMed ID: 26860903

SO-VID: 00b8ac8f-7066-4be8-a714-748fecd9832b

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.