1. Utilizing the Candida Score to Identify Patients at Increased Risk for
Invasive Candidiasis – a Retrospective Cohort Study
Tony Hidalgo, PharmD Candidate 2017, UTEP/UT Austin Cooperative Pharmacy Program, El Paso, TX
Enrique Soto-Ruiz, PharmD, University Medical Center, El Paso, TX
Celeste M. Vinluan, PharmD, BCPS, West Coast University School of Pharmacy, Los Angeles, CA
Ogechika Alozie, MD, MPH, Associate Professor, Texas Tech University Health Science Center, El Paso, TX
Objective
Assess potential risk factors for invasive candidiasis by calculating a Candida Score to initiate empiric antifungal therapy sooner and improve patient outcomes.
Methods
The study population consists of all non-neutropenic patients admitted to the intensive care unit from 2009 – 2011 with positive Candida in the blood or urine at University Medical Center in El Paso, Texas. A review of the study population was performed to calculate each patient’s Candida Score and risk factors for invasive candidiasis. Based on clinical data, calculation of the Candida Score was performed at the time of admission, then at each time point the patient presented with a new risk factor.
The following information was obtained from patients’ charts in order to calculate the Candida Score and provide patient demographics:
Age
Gender
Surgical date
Surgical procedure
Positive cultures (from any site)
Medication history
Progress notes (to assess criteria for sepsis and use of TPN)
Length of stay
Hospital outcomes (discharge or death)
Results
A total of 83 patients were included in this study to assess mortality stratified by Candida Score. The frequency of death is increased as the Candida Score increases (Figure 1).
The relationship between Candida Score and mortality showed a 0.7 decrease in survivability with every unit increase in Candida Score, indicating a positive relationship between Candida Score and mortality (p ).
Analysis of the relationship between Candida Score and mortality using patient age, gender, length of stay, and Candida Score using linear regression revealed that only patient age and Candida Score were significant predictors of death (p and , respectively).
An analysis to examine the relationship between number of days until treatment and its effect on mortality in those with a Candida Score > 3 indicated that delayed time to treatment was not significantly related to mortality (p ).
Discussion
As demand for judicious use of antimicrobials increases, many facilities nationwide have started to develop tools to identify patients at high risk for invasive infections. This study shows that it is possible to identify patients at increased risk of invasive candidiasis and mortality using risk factors to calculate a Candida Score. An important point from our study is that a Candida Score of at least 3 indicated increased risk for mortality, though delaying time to treatment did not affect mortality. In addition to Candida Score, patient age can also be considered a significant predictor of death.
Background
Candida species have been identified as the fourth most common cause of nosocomial bloodstream infections in the country.1 Mortality rates associated with invasive candidiasis (IC) are estimated to be over 40%; the highest pathogen-derived mortality in hospitals. Despite the risk IC carries, predominantly with increasing rates in non-neutropenic patients1,2, there is a lack of reliable methods to distinguish disseminated candidiasis from other types of candidiasis. The ability to distinguish clinically relevant IC from colonization can lead to earlier treatment and reduced mortality.
The Candida Score, which utilizes a point system for specific risk factors, was developed as a predictive tool to identify patients at high risk for developing IC who may benefit from early anti-fungal therapy.
Conclusion
This retrospective cohort study was performed to assess potential risk factors resulting in invasive candidiasis by using a Candida Score that would be predictive of mortality risk. Our study determined that a Candida Score > 3 was associated with increased risk of mortality. The use of a bedside tool such as the Candida Score can be used to identify patients at increased risk of invasive candidiasis and therefore prompt initiation of antifungal therapy in efforts to reduce mortality in an acute hospital setting.
Figure 1: Percent Mortality by CS (n=83)
Mortality (%)
Candida Score = 3
33.3
Candida Score = 4
15.8
Candida Score = 5
100.0
Table 2: Candida Score to Identify ICU Candidates for Empiric Antifungal Therapy
Multifocal Candida colonization
Severe sepsis
Surgery on ICU admission
Use of total parenteral nutrition (TPN)
One point for each risk factor, except for severe sepsis, which receives 2 points. Candida score > 2.5 has a sensitivity of 81% and specificity of 74% for invasive candidiasis.
Table 1: Baseline Demographics
Characteristics
Outcome
Mean Age
54.6 years
Gender (Female)
66.7%
Receiving TPN
8.7%
Positive for Sepsis
39.1%
Length of Stay (days)
32.2
Hospital outcomes (discharge)
76.8%
Reference:
David Schlossberg, ed Clinical Infectious Disease. New York. Cambridge University Press. ISBN-10: , ISBN-13: STAT!Ref Online Electronic Medical Library. 1/17/2012 4:21:01 PM CST (UTC -06:00).
Pappas P, Kauffman C, Andes D, et al. Clinical Practice Guidelines for the Management of Candidiasis: Update by the Infectious Diseases Society of America. CID 2009; 48:
Disclosures: All authors of this presentation have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation. IRB [E12047].
For more information please contact: Jose A. Hidalgo, PharmD Candidate 2017 at Presented at ASHP Annual Meeting, Las Vegas, NV, December 2016; Poster