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

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Presentation on theme: "A Bedside Scoring System (“Candida Score”) for Early antifungal Treatment in Nonneutropenic Critically Ill Patients with Candida Colonization Crit Care."— Presentation transcript:

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!!!

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