1. A Bedside Scoring System (“Candida Score”) for Early antifungal Treatment in Nonneutropenic Critically Ill Patients with Candida Colonization
Crit Care Med 2006 Vol.34, No.3, 730~737
Presented by Ri 李泳姿
2006/3/20

2. Case Present 75 y/o male patient Underlying gastric cancer s/p op
A-loop segmental ischemia s/p op
Fournier gangrene s/p debridement
Old intracranial hemorrhage
Hepatitis B carrier
Chronic obstructive pulmonary disease
Chronic renal insufficiency
Benign prostate hyperplasia s/p trans-urethral resection of prostate

3. Case Present
94/12/6: Gastric cancer, adenocarcinoma diagnosed at 萬芳 Hospital
12/19: Radical subtotal gastrectomy + B-II at NTUH
12/23: Abdominal pain and distension, fever, unstable hemodynamics, transfer to SICU
12/24: Intubation, CT: distended afferent-loop with segmental ischemic change of small bowel
12/25: Emergent operation for decompression  removal of Braun procedure, duodenostomy via Nelaton tube + feeding jejunostomy  post-op septic shock

4. Case Present
12/27: Swelling scrotum  MRI compatible with Fournier gangrene s/p debridement, with operation findings on 12/29 of scrotal abscess R/O abscess from internal ring
12/30: Bile content noted from internal ring s/p Nelaton tube drainage with irrigation wound suture on 95/1/9, wound culture and CVP culture both yielded Candida  Diflucan use
1/21: Close inguinal wound with Nelaton tube insertion
1/26: General ward
2/2: Fever with copious sputum, CXR: RLL pneumonia, SICU

5. Case Present
2/8: Hypotension with tachypnea; septic shock, Ciproxin use
2/9: Left retroperitoneal abscess by abdominal CT s/p pigtail drainage
2/10: Bilateral DVT s/p Clexane use
2/24: Septic shock R/O pneumonia-related; no new abscess by abdominal CT
3/1: CXR: left pleural effusion s/p pigtail drainage
3/2: Right inguinal wound culture: MRSA s/p Vancomycin
3/6 ACTH stimulation test showed relative adrenal insufficiency
3/16: Tracheostomy

6. A Bedside Scoring System (“Candida Score”) for Early antifungal Treatment in Nonneutropenic Critically Ill Patients with Candida Colonization

7. Introduction
Incidence of Candida infection increasing in critical care setting
Invasive cadidiasis associated with severe sepsis, septic shock and multiorgan failure
Estimated mortality rate of 40% despite new antifungal drugs
To obtain a simple scoring system in differentiating between Candida colonization and proven candidal infection while considering preemptive antifungal tretment

8. Methods Study population
1,765 patients from EPCAN project (Candidiasis Prevalence Study), age over 18 yrs, admitted for > 7 days to 73 medical-surgical ICUs in 70 tertiary care hospitals in Spain, between May 1998 to Jan 1999

9. Methods
Design
A prospective, cohort, observational and multicenter study
Screening cultures for Candida spp. on ICU admission and once a week thereafter until discharge or death
Sample sites: tracheal aspirates, pharyngeal exudates, gastric aspirates, urine, peripheral blood , iv lines, feces, wound exudates, surgical drains or infectious foci

10. Methods
Design
Patient data of age, gener, underlying disease, reason for ICU admission, concomitant infections, presence and duration of risk factors for candidal colonization and infection, antifungal treatment, and vital status at discharge (survival or death) were collected from the EPCAN database
Neutropenia as an exclusion criterion
Severity evaluating based on APACHE II system
Patients classified as surgical, trauma or medical

11. Methods Design Definition of underlying dz:
DM: insulin-treated patients
Chronic bronchitis: productive cough for >90 days/yr and for consecutive 2 yrs
Chronic liver dz: by liver biopsy or signs of portal hypertension
Chronic renal failure: those requiring H/D or P/D at admission
Severe heart failure: grade III and IV of NYHA

12. Methods Design Other risk factors: Arterial catheter CVC TPN
Enteral nutrition
Urinary catheter
Antibiotic treatment 10 days before admission
Hemodialysis or continuous hemofiltration
Steroid use

13. Methods Definitions of colonization and infection
Colonization: presence of Candida in nonsignificant samples from oropharynx, stomach, urine, or traheal aspirates
Unifocal colonization: from one focus
Multiple colonization: Candida spp. simultaneously isolated from various noncontiguous foci, even if two different spp.
Persistent colonization: at least two weekly consecutive sets of positive cultures

14. Methods Definitions of colonization and infection
Proven candidal infection:
Candidemia: one blood culture yielding a Candida spp.
Ophthalmic exam consistent with candidal endophthalmitis in patient with sepsis
Isolation from significant samples (pleural effusion, pericardial fluid) or candidal peritonitis
Catheter-related candidemia: intravascular device + >1 postive B/C + clinical manifestation of infection + no apparent source for blood stream infection + positive catheter culture (same organism as B/C)

15. Methods Definitions of colonization and infection
Patients classified into:
Neither colonized nor infected
Unifocal or multifocal candidal colonization without proven infection
Proven candidal infection

16. Results
58 candidemia, 30 peritonitis, 6 endophthalmitis, 3 candidemia plus peritonitis, 18 catheter-related candidemia
Median elapsed time between onset of infection and antifungal therapy was 12 days

17. Results
No statistically significant differences in the APACHE II scores between the three groups (APACHE II 18, 18, 17 respectively)
Statistically significant differences of risk for death between patient group and mortality

18. Results

19. Results

20. Results

21. Results
Sen: 81%
Spe: 74%

22. Discussion
Multifocal fungal colonization is an independent risk factor of candida infection (NEMIS: recovery of Candida spp. in rectal and urine not associating with bloodstream infection)
The colonization index = no. of culture-positive sites / the no. of sites cultured; if >=0.4, starting preemptive antifungal treatment is recommended in ICU patients
Piarroux et al.: incidence of ICU-acquired proven candidiasis significantly decreased from 2.2% to 0% (p<0.001) in patients with colonization index>=0.4

23. Discussion
The mortality rate increased significantly according to the patient group; unifocal (26.5%), multifocal (50.9%); proven infection (57.7%)
The role of candida colonization as a key factor in deciding treatment
Venous catheter not significant predictor of proven infection, opposing the pervious thoughts
Candida score= 1*TPN+1*surgery+1*multifocal candida colonization+2*sepsis; with a cut-off value of 2.5, sensitivity 81%, specificity 74%
Patient with score>2.5 are 7.75 times as likely to have proven infection than those <2.5
Assessment with candida score should be performed at time of ICU admission

24. Conclusion
A score>2.5 help intensivists select patients benefit from early antifungal administration
However, the benefits of preemptive (prophylactic or empirical) antifungal therapy remain to be determined

25. Reviewing this patient…
Candida score= 1*TPN + 1*surgery + 1*multifocal candida colonization + 2*sepsis
TPN: yes, for two weeks, start one week after ICU admission
Surgery: yes
Candida colonization: not routinely performed at admission, but at least one positive for frank wound culture
Sepsis: yes (first time on 12/23)
His candida score: 4.5 points
Positive culture of candida on 1/10 and Diflucan used thereafter
Time relapsed: over two weeks

26. Thank you for your attention!!!