Abstract
IntroductionAlthough prompt initiation of appropriate antifungal therapy is essential for the control of invasive Candida infections and an improvement of prognosis, early diagnosis of invasive candidiasis remains a challenge and criteria for starting empirical antifungal therapy in ICU patients are poorly defined. Some scoring systems, such as the "Candida score" could help physicians to differentiate patients who could benefit from early antifungal treatment from those for whom invasive candidiasis is highly improbable. This study evaluated the performance of this score in a cohort of critically ill patients.MethodsA prospective, observational, multicenter, cohort study was conducted from January 2010 to March 2011 in five intensive care units in Nord-Pas de Calais, an area from North of France. All patients exhibiting, on ICU admission or during their ICU stay, a hospital-acquired severe sepsis or septic shock could be included in this study. The data collected included patient characteristics on ICU admission and at the onset of severe sepsis or septic shock. The "Candida score" was calculated at the onset of sepsis or shock. The incidence of invasive candidiasis was determined and its relationship with the value of the "Candida score" was studied.ResultsNinety-four patients were studied. When severe sepsis or shock occurred, 44 patients had a score = 2, 29 patients had a score = 3, 17 patients had a score = 4, and 4 patients had a score = 5. Invasive candidiasis was observed in five (5.3%) patients. One patient had candidemia, three patients had peritonitis, and one patient had pleural infection. The rates of invasive candidiasis was 0% in patients with score = 2 or 3, 17.6% in patients with score = 4, and 50% in patients with score = 5 (p < 0.0001).ConclusionsOur results confirm that the "Candida score" is an interesting tool to differentiate among ICU patients who exhibit hospital-acquired severe sepsis or septic shock those would benefit from early antifungal treatment (score > 3) from those for whom invasive candidiasis is highly improbable (score ≤ 3).
Highlights
Prompt initiation of appropriate antifungal therapy is essential for the control of invasive Candida infections and an improvement of prognosis, early diagnosis of invasive candidiasis remains a challenge and criteria for starting empirical antifungal therapy in intensive care unit (ICU) patients are poorly defined
In 2009, the same group demonstrated a significant linear association between increasing values of the “Candida score” and the rate of invasive Candida infections [22]. Such a score could be useful to stratify the risk of proven Candida infection and differentiate patients who would benefit from early antifungal treatment from those for whom invasive candidiasis is highly improbable
Among the 21 patients with a “Candida score” >3, mortality was not different for patients who received or did not receive empiric antifungal treatment (6/10 vs. 7/11; p = 1). This prospective cohort study confirms that the “Candida score” is an interesting tool to differentiate, among ICU patients with hospital-acquired severe sepsis or septic shock, those who would benefit from early antifungal treatment from those for whom invasive candidiasis is highly improbable
Summary
Prompt initiation of appropriate antifungal therapy is essential for the control of invasive Candida infections and an improvement of prognosis, early diagnosis of invasive candidiasis remains a challenge and criteria for starting empirical antifungal therapy in ICU patients are poorly defined. Some scoring systems, such as the “Candida score” could help physicians to differentiate patients who could benefit from early antifungal treatment from those for whom invasive candidiasis is highly improbable. Recent IDSA guidelines suggest that “empirical antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever” [14]. Widespread use of antifungal agents would be associated with substantially increased overall health care costs and emergence of resistance [16,17]
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