Medicine

1. Candida Score: a Predictor of
Mortality in Patients with
Candidemia
Moderator : Dr. Bhumesh Thyagi
PRESENTED BY :Dr. A.L.S. Vara Prasad

2. INTRODUCTION
Candida spp. is the most common cause of opportunistic fungal infections worldwide.
• Candida are generally a part of normal microbial flora of skin and mucous membrane in immune-
competent individuals but may cause severe systemic infections in critically ill patients with
underlying disease such as diabetes mellitus, prolonged duration of stay in intensive care unit
(ICU), or other factors which may suppress the immunity.
• They may cause a wide variety of infections, ranging from mild mucocutaneous to severe
invasive infections that can involve virtually any organ. Term candidemia describes the presence
of Candida spp in blood stream. It is a life threatening fungal infection associated with a mortality
rate of 38%. It also prolongs hospital stays by as much as 30 days and increases the cost of
medical care.
• Candida spp. is one of the most common causes of bloodstream infection among the patients
admitted in the ICU.
• Although Candida albicans remains the most prevalent species globally, there has been a clear
shift towards non-albicans species namely Candida tropicalis, Candida parapsilosis, Candida
kruzei particularly found in the neutropenic patients and Candida glabrata found especially in
patients with solid tumor.

3. • Prompt and accurate diagnosis of invasive fungal infection is crucial so that
appropriate antifungal agents can be started rapidly. Several prediction rules and
scores based on clinical, laboratory, and microbiological parameters have been
proposed to help clinicians identify patients at high risk of developing invasive fungal
infections.
• Many scores and prediction models have been proposed for early identification of
invasive candidiasis and help in early initiation of antifungal therapy, like candida score,
clinical prediction rule, CI, and CCI. Among these the candida score is arguably one of
the most studied and validated score among different ICU populations.

4. • The Candida score, an easy-to-use bed side assessment system which integrates four risk factors (total
parenteral nutrition, surgery, multifocal Candida colonization, and severe sepsis).
• The Candida score has been developed and used for identifying patients at risk for developing candida
infections.
• This study aimed to determine the epidemiology of candidemia and evaluate the risk factors for mortality in
patients with candidemia admitted to an Indian medical ICU.

5. Material and Methods
• Medical records of 18 month duration, from May 2012 to October 2013, of all the ICU admissions
in a tertiary care hospital in New Delhi were analysed for presence of candidemia. A total of 3142
ICU admissions were screened and 56 patients with candidemia were selected for further
analysis and outcome study.
• For the purpose of categorization of patients, previous antibiotic use was defined as use of at
least two broad spectrum antibiotics for more than 72 hours in the current hospital admission.
Previous antifungal use was defined as any antifungal use in the current hospital admission.
• The Candida score was calculated. These data was further analyzed for the primary outcome
measure, ICU mortality.

6. Blood culture and organism identification
• For diagnosis of candidemia or bacteraemia, 5–10 ml blood was collected in aerobic blood culture
bottles .
• The bottles were incubated and monitored regularly .All positive samples were processed for
microbial identification and antifungal susceptibility.
Statistical analysis
• quantitative data were analysed. Qualitative data were analyzed using Chi square or Fisher Exact
tests and quantitative data were analyzed using Student’s t-test.
• Univariate and multivariate analysis were done to find out the factors associated with ICU
mortality. All tests were two tailed, with p< 0.05 being considered significant.
• Primary outcome measure was ICU mortality.
• Secondary outcome measures were organ support, which included requirement of inotropes, renal
replacement therapy and mechanical ventilation and length of stay in ICU and hospital

7. RESULT
• A total of 3,142 patients were admitted to ICU during the period of study. The incidence of
candidemia was 17.8/1,000 admissions.
• Majority of patients (87.5%) had central venous catheters in place and were using
antimicrobials (87.5%) before developing candidemia.

8. • Patient parameters such as age, admission APACHE II score, candida score, previous antifungal
therapy and underlying co-morbidities, which were statistically significant in differentiating
survivors and non-survivors in the univariate analysis, [Table 2] were included in the multi-variate
analysis.
• Among the patients with candidemia, 5 3 . 6 % required vasopressor support, 41.1% required
renal replacement therapy (RRT) and 64.3% required mechanical ventilation during their ICU
stay.

9. Discussion
• Contemporary studies have reported that non-albicans candida (tropicalis) infection, old age, co-
morbidities, higher APACHE II score, worsening organ dysfunction, septic shock and use of
corticosteroids is associated with increased risk of mortality.
• Furthermore, In this found that two factors, previous antifungal use and Candida score >3 were
independent predictors of ICU mortality.

10. Conclusion
• Candida infection is generally late on set in ICU patients and is associated with prolonged ICU and hospital
stays, and a high mortality. In this study there was no difference in mortality among patients with albicans
and non-albicans infection.
• Patients who develop candidemia, inspite being on antifungal therapy, were at a higher risk of dying and a
simple bedside candida score (>3) may be useful in predicting mortality of ICU patients with candidemia.

11. Thank you