Candidaemia and a risk predictive model for overall mortality: a prospective multicentre study

C Keighley,S C-A Chen,H L Wilson,N Underwood,K Mcdonald,D Marriott,K Kennedy,J Darvall,K Hajkowicz,T C Sorrell,Q Nguyen,C Halliday,M A Slavin,S Van Hal,N Bak,A Pope,S Kidd,B Chapman

doi:10.1186/s12879-019-4065-5

Abstract

BackgroundCandidaemia is associated with high mortality. Variables associated with mortality have been published previously, but not developed into a risk predictive model for mortality. We sought to describe the current epidemiology of candidaemia in Australia, analyse predictors of 30-day all-cause mortality, and develop and validate a mortality risk predictive model.MethodsAdults with candidaemia were studied prospectively over 12 months at eight institutions. Clinical and laboratory variables at time of blood culture-positivity were subject to multivariate analysis for association with 30-day all-cause mortality. A predictive score for mortality was examined by area under receiver operator characteristic curves and a historical data set was used for validation.ResultsThe median age of 133 patients with candidaemia was 62 years; 76 (57%) were male and 57 (43%) were female. Co-morbidities included underlying haematologic malignancy (n = 20; 15%), and solid organ malignancy in (n = 25; 19%); 55 (41%) were in an intensive care unit (ICU). Non-albicans Candida spp. accounted for 61% of cases (81/133). All-cause 30-day mortality was 31%. A gastrointestinal or unknown source was associated with higher overall mortality than an intravascular or urologic source (p < 0.01). A risk predictive score based on age > 65 years, ICU admission, chronic organ dysfunction, preceding surgery within 30 days, haematological malignancy, source of candidaemia and antibiotic therapy for ≥10 days stratified patients into < 20% or ≥ 20% predicted mortality. The model retained accuracy when validated against a historical dataset (n = 741).ConclusionsMortality in patients with candidaemia remains high. A simple mortality risk predictive score stratifying patients with candidaemia into < 20% and ≥ 20% 30-day mortality is presented. This model uses information available at time of candidaemia diagnosis is easy to incorporate into decision support systems. Further validation of this model is warranted.

Highlights

The shift in aetiology of candidaemia towards non-albicans Candida spp. and in particular, the disproportionate increase of Candida glabrata complex infections is of concern [2, 4]
A number of studies have found that mortality increases with age (e.g. > 65 years), admission to an intensive care unit (ICU), use of total parenteral nutrition (TPN) or broad-spectrum antibiotics, organ dysfunction and a gastrointestinal source of candidaemia [6, 8,9,10,11]
We conducted a contemporary multicentre, prospective study of the epidemiology and complications of candidaemia in Australia and assessed factors influencing mortality. Based on these data we propose a simple risk prediction model for overall mortality using clinical and laboratory variables known at the time of notification of a positive blood culture

Summary

Introduction

Variables associated with mortality have been published previously, but not developed into a risk predictive model for mortality. We sought to describe the current epidemiology of candidaemia in Australia, analyse predictors of 30-day all-cause mortality, and develop and validate a mortality risk predictive model. Candidaemia (or bloodstream infection with Candida spp.) continues to increase and ranks amongst the top 5 hospital-acquired infections in many countries [1,2,3,4,5]. Mortality from candidaemia remains high (up to 40%) with prolonged hospital stay and excess costs [1,2,3, 5,6,7]. Better understanding of the variables that influence mortality is essential to improving outcomes in patients with candidaemia. Delays in source control and initiation of appropriate antifungal therapy adversely affect outcomes [12, 13]

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