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Usefulness of the “Candida score” for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: A prospective multicenter study

León, Cristóbal MD; Ruiz-Santana, Sergio MD, PhD; Saavedra, Pedro PhD; Galván, Beatriz MD; Blanco, Armando MD; Castro, Carmen MD; Balasini, Carina MD; Utande-Vázquez, Aránzazu MD; González de Molina, Francisco J. MD; Blasco-Navalproto, Miguel A. MD; López, Maria J. MD; Charles, Pierre Emmanuel MD, PhD; Martín, Estrella PhD; Hernández-Viera, María Adela MD

doi: 10.1097/CCM.0b013e31819daa14
Clinical Investigations
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Objective: To assess the usefulness of the “Candida score” (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point.

Design: Prospective, cohort, observational study.

Setting: Thirty-six medical-surgical intensive care units of Spain, Argentina, and France.

Patients: A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007.

Measurements and Main Results: Clinical data, surveillance cultures for fungal growth, and serum levels of (1–3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition ×1, plus surgery ×1, plus multifocal Candida colonization ×1, plus severe sepsis ×2. A CS ≥3 accurately selected patients at high risk for IC. The colonization index was registered if ≥0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06–3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p ≤ 0.001). The area under the receiver operating characteristic curve for CS was 0.774 (95% CI 0.715–0.832) compared with 0.633 (95% CI 0.557–0.709) for CI. (1–3)-Beta-d-glucan was also an independent predictor of IC (odds ratio 1.004, 95% CI 1.0–1.007). The relative risk for developing IC in colonized patients without antifungal treatment was 6.83 (95% CI 3.81–12.45).

Conclusions: In this cohort of colonized patients staying >7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.

From the Intensive Care Unit (CL), Hospital Universitario de Valme, Universidad de Sevilla, Sevilla, Spain; Intensive Care Unit (R-S, AH-V), Hospital Universitario Dr. Negrín, Universidad de las Palmas de Gran Canaria, Spain; Mathematics Department (PS), Universidad de las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain; Intensive Care Unit (BG), Hospital Universitario La Paz, Madrid, Spain; Intensive Care Unit (AB), Hospital Central de Asturias, Oviedo, Spain; Service of Clinical Microbiology (CC, EM), Hospital Universitario de Valme, Universidad de Sevilla, Sevilla, Spain; Intensive Care Unit (CB), Hospital Interzonal General de Agudos, San Martín de la Plata, Argentina; Intensive Care Unit (AU-V), Hospital Universitario Miguel Servet, Zaragoza, Spain; Intensive Care Unit (FJGDM), Hospital Mútua de Terrassa, Terrassa, Barcelona, Spain; Intensive Care Unit (AB), Hospital Severo Ochoa, Leganés, Madrid, Spain; Intensive Care Unit (MJL), Hospital General Yagüe, Burgos, Spain; and Service de Réanimation Médicale (PEC), Hôpital Le Bocage, Dijon, France.

Supported, in part, by a grant from Gilead Sciences, S.L., Madrid, Spain. Gilead Sciences had no role in the collection, analysis, or interpretation of data or in the decision to submit the study for publication.

The authors have not disclosed any potential conflicts of interest.

Study concept and design: León, Ruiz-Santana, Saavedra, Charles; Acquisition of data: León, Ruiz-Santana, Saavedra, Galván, Blanco, Balasini, Utande, González, Blasco-Navalproto, López, Charles, Hernández-Viera; Analysis and interpretation of data: León, Ruiz-Santana, Saavedra, Charles; Drafting of the manuscript: León, Ruiz-Santana, Saavedra, Galván, Blanco, Castro, Balasini, Utande-Vázquez, González, Blasco-Navalproto, López, Charles, Martín, Hernández-Viera; Critical revision of the manuscript for important intellectual content: León, Ruiz-Santana, Saavedra; Statistical analysis: Saavedra; Obtained funding: León; Administrative, technical, or material support: León, Ruiz-Santana, Saavedra, Galvan Castro, Martin; Study supervision: León, Ruiz-Santana, Saavedra, Charles; Approval of the final draft: León, Ruiz-Santana, Saavedra, Galván, Blanco, Castro, Balasini, Utande-Vázquez, González de Molina, Blasco-Navalproto, López, Charles, Martín, Hernández-Viera.

Presented, in part, at the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, IL, September 17–20, 2007.

Dr. León had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

For information regarding this article, E-mail: cleong@telefonica.net

© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins