Candida Score-5.pptx

Candida score

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.  T his 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

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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