Presented by Dr WONG Kin Wa at the daily Journal Club, ICU, PYNEH, Hong Kong, on 13 May 2009
What is "Candida score"?
A. A score which reflects the degree of azole resistance in various species of Candida
B. A lower score is predictive of a lower likelihood of invasive candidiasis (IC) in a Candida-colonized non-neutropenic critically ill patient
C. A higher score is related to higher mortality rate from invasive Candidiasis in immunocompetent patients
D. A higher score is related to a higher likelihood of Candidal pneumonia in critically ill patients
Answer: B
Editor’s Impression
Because of its only moderate ROC area and the requirement for some, though easy, calculations, one may not put this to routine clinical use till further trials. However, in the meantime, it is still useful to know that absence of the following factors are related to a lower likelihood of invasive candidiasis:
total parenteral nutrition, surgery, multifocal Candida colonization, and particularly severe sepsis.
Reference
Leon, Cristobal MD; Ruiz-Santana, Sergio MD, PhD; Saavedra, Pedro PhD; Galvan, Beatriz MD; Blanco, Armando MD; Castro, Carmen MD; Balasini, Carina MD; Utande-Vazquez, Aranzazu MD; Gonzalez de Molina, Francisco J. MD; Blasco-Navalproto, Miguel A. MD; Lopez, Maria J. MD; Charles, Pierre Emmanuel MD, PhD; Martin, Estrella PhD; Hernandez-Viera, Maria Adela MD; on behalf of the Cava Study Group. Usefulness of the "Candida score" for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: A prospective multicenter study. Critical Care Medicine. 37(5):1624-1633, May 2009. Abstract at CCM website here.
Objective: To assess the usefulness of the "Candida score" (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point.
Design: Prospective, cohort, observational study.
Setting: Thirty-six medical-surgical intensive care units of Spain, Argentina, and France.
Patients: A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007.
Measurements and Main Results: Clinical data, surveillance cultures for fungal growth, and serum levels of (1-3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition x1, plus surgery x1, plus multifocal Candida colonization x1, plus severe sepsis x2. A CS >=3 accurately selected patients at high risk for IC. The colonization index was registered if >=0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06-3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p <= 0.001). The area under the receiver operating characteristic curve for CS was 0.774 (95% CI 0.715-0.832) compared with 0.633 (95% CI 0.557-0.709) for CI. (1-3)-Beta-d-glucan was also an independent predictor of IC (odds ratio 1.004, 95% CI 1.0-1.007). The relative risk for developing IC in colonized patients without antifungal treatment was 6.83 (95% CI 3.81-12.45).
Conclusions: In this cohort of colonized patients staying >7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.