This study aimed to determine the epidemiology of candidemia and evaluate risk factors for mortality in patients with candidemia admitted to an Indian medical ICU. The incidence of candidemia was found to be 17.8 per 1,000 ICU admissions. Non-albican species accounted for 78.6% of candidemia. Previous antifungal use and a Candida score greater than 3 were found to independently predict increased ICU mortality. The Candida score integrates several risk factors and may provide a useful bedside tool for predicting mortality in patients with candidemia.

1. Candida Score: a Predictor of
Mortality in Patients with
Candidemia
Moderator : Dr. Bhumesh Thyagi
PRESENTED BY :Dr. A.L.S. Vara Prasad

2. INTRODUCTION
Candida spp. is the most common cause of opportunistic fungal infections worldwide.
• Candida are generally a part of normal microbial flora of skin and mucous membrane in
immune-competent individuals but may cause severe systemic infections in critically ill
patients with underlying disease such as diabetes mellitus, prolonged duration of stay in
intensive care unit (ICU), or other factors which may suppress the immunity.
• They may cause a wide variety of infections, ranging from mild mucocutaneous to severe
invasive infections that can involve virtually any organ.
• Term candidemia describes the presence of Candida spp in blood stream. It is a life
threatening fungal infection associated with a mortality rate of 38%.
• It also prolongs hospital stays by as much as 30 days and increases the cost of medical
care.

3. • Candida spp. is one of the most common causes of bloodstream infection among the patients
admitted in the ICU.
Candida albicans remains the most prevalent species globally, there has been a clear shift towards
non-albicans species namely Candida tropicalis, Candida parapsilosis, Candida kruzei particularly
found in the neutropenic patients and Candida glabrata found especially in patients with solid tumor

4. .
• Prompt and accurate diagnosis of invasive fungal infection is crucial so that
appropriate antifungal agents can be started rapidly. Several prediction rules and
scores based on clinical, laboratory, and microbiological parameters have been
proposed to help clinicians identify patients at high risk of developing invasive fungal
infections.
• Many scores and prediction models have been proposed for early identification of
invasive candidiasis and help in early initiation of antifungal therapy, like candida score,
clinical prediction rule, CI, and CCI. Among these the candida score is arguably one of
the most studied and validated score among different ICU populations.

5. .
• The Candida score, an easy-to-use bed side assessment system which integrates four risk factors (total
parenteral nutrition, surgery, multifocal Candida colonization, and severe sepsis).

6. • The Candida score has been developed and used for identifying patients at risk for developing
candida infections.
• This study aimed to determine the epidemiology of candidemia and evaluate the risk factors for
mortality in patients with candidemia admitted to an Indian medical ICU.

7. Material and Methods
• Medical records of 18 month duration, from May 2012 to October 2013, of all the ICU admissions
in a tertiary care hospital in New Delhi were analysed for presence of candidemia. A total of 3142
ICU admissions were screened and 56 patients with candidemia were selected for further
analysis and outcome study.
• For the purpose of categorization of patients, previous antibiotic use was defined as use of at
least two broad spectrum antibiotics for more than 72 hours in the current hospital admission.
Previous antifungal use was defined as any antifungal use in the current hospital admission.
• The Candida score was calculated. These data was further analyzed for the primary outcome
measure, ICU mortality.
• Secondary outcome measures were organ support, which included requirement of inotropes,
renal replacement therapy and mechanical ventilation and length of stay in ICU and hospital

8. .
Statistical analysis
• quantitative data were analysed. Qualitative data were analyzed using Chi square or Fisher Exact
tests and quantitative data were analyzed using Student’s t-test.
• Univariate and multivariate analysis were done to find out the factors associated with ICU
mortality. All tests were two tailed, with p< 0.05 being considered significant.

9. • Result
A total of 3,142 patients were admitted to ICU during the period of study. The incidence of
candidemia was 17.8/1,000 admissions.
Majority of patients (87.5%) had central venous catheters in place and were using antimicrobials
(87.5%) before developing candidemia

10. .

11. Patient parameters such as age, admission APACHE II score, candida score, previous antifungal
therapy and underlying co-morbidities, which were statistically significant in differentiating survivors
and non-survivors in the univariate analysis, [Table 2] were included in the multi-variate analysis.
• Among the patients with candidemia, 5 3 . 6 % required vasopressor support, 41.1% required
renal replacement therapy (RRT) and 64.3% required mechanical ventilation during their ICU
stay.

12. Discussion
• Contemporary studies have reported that non-albicans candida (tropicalis) infection, old age, co-
morbidities, higher APACHE II score, worsening organ dysfunction, septic shock and use of
corticosteroids is associated with increased risk of mortality.
• Furthermore, In this found that two factors, previous antifungal use and Candida score >3 were
independent predictors of ICU mortality.

13.  In our retrospective cohort study the incidence of candidemia was found to be 17.8/1000 ICU
admissions and non albicans species were found to the predominant isolates (78.6%). A great
majority of patients (87.5%) had CVCs and previous exposure to antibiotics. In multivariate
analysis, that previous antifungal exposure and candida score of >3 were found to be
independent predictors of ICU mortality.Candida infection is the most common opportunistic
infection worldwide with a reported incidence ranging from 6.5/1000 to 110/1000 ICU
admissions.1 This wide variation may be attributed to different patient populations being
studied, capricious reporting of incidence rates and variable denominators in different
studies.13–20 Our reported incidence of 17.8/1,000 admissions, was well within this range.
In the present study, non-albicans candid aspp accounted for 78.6% of total candidemia with
C. tropicalis being the most common candida isolated. A similar trend towards increasing
nonalbicans candidemia has been reported in various Indian ICUs with studies reporting an
incidence up to 84%.15–20 This trend is in stark contrast with the contemporary
epidemiological studies of candidemia coming from developed, temperate climate
countries.21,22This difference in distribution of species among the climate zones may
probably help explain the disparate crude mortality figures reported from various part of the
world in ICU patients with candidemia. It emphasizes the importance of knowing the local
epidemiology as the empiric treatment and overall patient prognosis depends on it as
inappropriate initial antifungal therapy has been shown to be associated with poorer

14.  Several studies have shown that the presence of CVCs and previous antibiotic use are
associated with increased risk of development of candidemia.15,17,20 In our patient cohort
too, we found that 87.5% patients had CVC in place and had a history of previous antibiotic
use.Many scores and prediction models have been proposed for early identification of invasive
candidiasis and help in early initiation of antifungal therapy, like candida score, clinical
prediction rule, CI, and CCI. Among these the candida score is arguably one of the most
studied and validated score among different ICU populations.9–11,24,25 The candida score,
an easy-to-use bed side assessment tool, was first proposed by Leon et al for ascertaining
need of antifungal treatment in case of candida colonization in neutropenic patients.9 Later
it has been validated for nonneutropenic patients also.10 It integrates four risk factors (total
parenteral nutrition, surgery, multifocal candida colonization, and severe sepsis) and also has
a high negative predictive value (0.98) to rule out invasive candidiasis.10 But this score has
never been evaluated as a prognostication model for prediction of mortality.Contemporary
studies have reported that non-albicans candida (tropicalis) infection, old age, co-
morbidities, higher APACHE II score, worsening organ dysfunction, septic shock and use of
corticosteroids is associated with increased risk of mortality.26–28 Whereas, in our study
APACHE II score, status of comorbidities, use of antibacterial agents, use of CVCs and TPN
was not associated with any increase risk of mortality. Furthermore, we found that two
factors, previous antifungal use and Candida score >3 were independent predictors of ICU
mortality.

15. Association of candida score with ICU mortality, may not be very surprising as the various components
of candida score have been separately reported to be associated with poor prognosis in previous
studies also.21,23,26–29A study has found that prior antifungal exposure leads to higher chances of
non-albicans candida (most commonly C. tropicalis) infections and increase in mortality.20 Although
our study did not find any difference in albicans and non-albicans candida mortality, but other studies
report that non-albicans candida infections have high rates of azole resistance and hence may be
associated with increased mortality.16,28 One of the reasons why we did not find any difference in
mortality among albicans and nonalbicans infection could have been that we had initiated anti-fungal
therapy with echinocandins in almost all of our patients as they were critically ill and azoles were
never used as the treatment of choice.This study has several strengths. It provides vital data for
epidemiology of candidemia in medical ICU population, as other contemporary regional studies have
included surgical patients that have significantly higher prevalence of candidemia.15–20 Till date, no
candidemia specific prognostication model or mortality predictor

16. Till date, no candidemia specific prognostication model or mortality predictor tool is available. Hence,
critical care physicians have to rely on general prediction models like APACHE II and sequential organ failure
assessment (SOFA) score to predict the severity of disease and disease outcome. As described above various
researchers have suggested different factors that may affect outcome of these patients but none have
evaluated the utility of any specific score for prognostication in patients with candidemia. Although our’s is
a retrospective study, it is a pioneering effort in the direction of predicting severity of candida disease and
gives a positive correlation between candida score and mortality. These results if evaluated in a larger
study, may provide a strong bedside and quick assessment tool to predict mortality in these patients.A few
limitations of the present study should be noted. First, this study was inherently retrospective in design and
thus missing values and potential information bias may have arisen. Second, in-vitro susceptibility results
were only available for the preserved isolates, and appropriate or inappropriate therapy could not be
defined for all of the study population. As a result, the analysis of mortality did not include the use of
specific antifungal agents. Further multicentre prospective studies are needed to evaluate these results as
well as investigate the impact of antifungal therapy and catheter removal on the prognosis of patients

17. Conclusion
• Candida infection is generally late on set in ICU patients and is associated with prolonged ICU and hospital
stays, and a high mortality. In this study there was no difference in mortality among patients with albicans
and non-albicans infection.
• Patients who develop candidemia, inspite being on antifungal therapy, were at a higher risk of dying and a
simple bedside candida score (>3) may be useful in predicting mortality of ICU patients with candidemia.

18. Thank you