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A bedside scoring system (“Candida score”) for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization*

León, Cristóbal MD; Ruiz-Santana, Sergio MD, PhD; Saavedra, Pedro PhD; Almirante, Benito MD, PhD; Nolla-Salas, Juan MD, PhD; Álvarez-Lerma, Francisco MD, PhD; Garnacho-Montero, José MD; León, María Ángeles MD, PhD

doi: 10.1097/01.CCM.0000202208.37364.7D
Clinical Investigations

Objective: To obtain a score for deciding early antifungal treatment when candidal infection is suspected in nonneutropenic critically ill patients.

Design: Analysis of data collected from the database of the EPCAN project, an ongoing prospective, cohort, observational, multicenter surveillance study of fungal infection and colonization in intensive care unit (ICU) patients.

Setting: Seventy-three medical-surgical ICUs of 70 teaching hospitals in Spain.

Patients: A total of 1,699 ICU patients aged 18 yrs and older admitted for at least 7 days between May 1998 and January 1999 were studied.

Interventions: Surveillance cultures of urine, tracheal, and gastric samples were obtained weekly. Patients were grouped as follows: neither colonized nor infected (n = 719), unifocal or multifocal Candida colonization (n = 883), and proven candidal infection (n = 97). The odds ratio (OR) for each risk factor associated with colonization vs. proven candidal infection was estimated. A logistic regression model was performed to adjust for possible confounders. The “Candida score” was obtained according to the logit method. The discriminatory power was evaluated by the area under the receiver operating characteristics curve.

Measurements and main results: In the logit model, surgery (OR = 2.71, 95% confidence interval [CI], 1.45–5.06); multifocal colonization (OR = 3.04, 95% CI, 1.45–6.39); total parenteral nutrition (OR = 2.48, 95% CI, 1.16–5.31); and severe sepsis (OR = 7.68, 95% CI, 4.14–14.22) were predictors of proven candidal infection. The “Candida score” for a cut-off value of 2.5 (sensitivity 81%, specificity 74%) was as follows: parenteral nutrition, +0.908; surgery, +0.997; multifocal colonization, +1.112; and severe sepsis, +2.038. Central venous catheters were not a significant risk factor for proven candidal infection (p = .292).

Conclusions: In a large cohort of nonneutropenic critically ill patients in whom Candida colonization was prospectively assessed, a “Candida score” >2.5 accurately selected patients who would benefit from early antifungal treatment.

From the Intensive Care Unit (CL), Hospital Universitario de Valme, Universidad de Sevilla, Sevilla; Intensive Care Unit, Hospital Universitario Dr. Negrín (SRS), and Mathematics Department (PS), Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria; Infectious Diseases Unit (BA), Hospital Universitari Vall d’Hebron, Universitat Autònoma, Barcelona; Intensive Care Unit (JN, FAL), Hospital Universitari del Mar, Universitat Autònoma, Barcelona; Intensive Care Unit (JGM), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla; and Intensive Care Unit (MAL), Hospital General de Catalunya, Barcelona, Spain.

See Appendix for list of EPCAN Study Group participants.

Supported in part by a grant from Gilead Sciences, S.L., Madrid, Spain.

The authors declare that they have no competing interests.

This study was presented in part at the 34th Critical Care Congress of the Society of Critical Care Medicine, Phoenix, Arizona, January 15–19, 2005.

Address requests for reprints to: Cristóbal León, MD, Intensive Care Unit, Hospital Universitario de Valme, Universidad de Sevilla, Carretera de Cádiz s/n, E-41014, Sevilla, Spain. E-mail:

© 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins