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Assessing the Risk for Invasive Candidiasis in the ICU

A score based on clinical parameters was helpful in determining the risk.

Invasive fungal infections in critically ill patients are worrisome because diagnosis is difficult and the mortality rate is high. Researchers recently developed a "Candida score" (CS) to assess the risk for invasive candidiasis (IC) in such patients. The score was calculated by assigning one point each for total parenteral nutrition, surgery, and multifocal Candida colonization and two points for severe sepsis. Now, the same research group — with partial support from industry — has conducted a prospective observational cohort study to evaluate the CS.

The study involved 1107 nonneutropenic adults treated between April 2006 and June 2007 for 7 days in any of 36 medical–surgical ICUs in Spain, Argentina, and France. The mean age of the patients was 60, and 67% were male. The mean APACHE II score at ICU admission was 18.4; the median SOFA score was 7. Median ICU and hospital stays were 17 and 37 days, respectively, and ICU and hospital mortality rates were 22% and 31%.

Twenty percent of the patients were neither colonized nor infected with Candida, 75% were colonized at 1 site, and 5% developed IC. Most IC cases were detected during patients’ second or third ICU week. IC occurred in 2% of patients with a CS <3 and in 9%, 17%, and 24% of those with a CS of 3, 4, and 5, respectively. The association between increasing CS values and IC incidence was highly significant. Among patients with Candida colonization or invasive fungal infection, (1–3)-β-D-glucan serum levels were measured for 240, and anti-Candida antibody titers were determined for 323. A CS 3 and a (1–3)β-D-glucan serum level >75 pg/mL were independent predictors of IC; anti-Candida antibody titers were not useful in this regard.

Comment: Empirical antifungal therapy is commonly administered to critically ill patients, with the potential for overuse. This simple CS, based solely on clinical parameters, seems useful for targeting such treatment more accurately.

— Thomas Glück, MD

Published in Journal Watch Infectious Diseases June 10, 2009

Citation(s):

León C et al. Usefulness of the "Candida score" for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: A prospective multicenter study. Crit Care Med 2009 May; 37:1624.

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• clarification
  h.p. bechinski, 13 Jun 2009 4:53 PM EST
  how do you calculate the CS score. At what length of ICU stay do you check And what anticandidal medication... [more]