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Introduction: Candidasis
is a growing problem, particularly in hospital intensive care unit
(ICU).Currently, invasive candidiasis includes more than 17% of nosocomial
infections in patients admitted to the intensive care units, timely diagnosis
and treatment is life saving. Unfortunately current candida score based on
clinical indices, has low specificity.

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Goals: This
study suggests the development of a new scoring system taking into account all
risk factors for invasive candidate that will have better sensitivity and

Methods: The
ICU patients at risk of candida infections were identified using traditional
candida score. Then, candida culture test was performed for all of the patients
at risk since admission in ICU and once a week until discharge from the ICU or
death. The data were analyzed in a modified candida scoring system introduced
in this article, to compare of the specificity and sensitivity in tow scoring

Results: All
of the risk factors include Total Parenteral Nutrition (TPN),Central Venous
Catheter (CVC), Broad antibiotic therapy, abdominal surgery, ICU stay
days> 7, pancreatitis, were associated with candidiasis infection (p
<0.05). The sensitivity of two Scoring system in patients with positive cultures was not significantly different together (p = 0.34), but significantly higher specificity was revealed in modified candida scoring compared with traditional candida scoring (p = 0.022). Conclusion: Using of suggested modified candida score in this research has higher specificity than candida score. Established risk factors of invasive candida in patients included in our study were similar to other studies. Keywords: Candidiasis, Candida score, Modified candida scoring, sensitivity, specificity. Introduction Candida albicans is one of common infectious agents. This dimorphic yeast is a commensal that colonizes skin, the gastrointestinal and the reproductive tracts (1).It can especially cause infection in hospitalized patients. The fourth most frequent cause of nosocomial bloodstream infection among ICU patients is Candida species, in some countries. The incidence of infections caused by Candida species in the critical care setting has substantially increased in recent years (2, 3). Invasive candidiasis includes candidemia, disseminated candidiasis with deep organ involvement, endocarditis and meningitis (4).Invasive Candida infections are the most common invasive fungal infections, accounting for 70-90% of all invasive mycoses (5,6). Incidence of candidemia varies between 0.5 and 1.4 per 10,000 patient-days in hospital and between 2 and 6.9 per 1,000 admissions in theintensive care unit (ICU) (7-10).Invasive candidiasis is associated with high mortality, especially in ICUs (3,11-12). Prompt initiation of appropriate antifungal therapy is essential for the control of invasive Candida infections and has been shown to reduce mortality (13-14). Unfortunately, early diagnosis of invasive candidiasis remained as a challenge, and criteria for starting empirical antifungal therapy in ICU patients are poorly defined (3). Risk factors for invasive candidiasis are well identified such as neutropenia , cancer chemotherapy, colonization with candida spp, broad-spectrum antibiotic usage , Presence of a central venous catheter, renal failure or hemodialysis, severity of illness (APACHE score), parenteral nutrition, Mechanical ventilation, prior abdominal surgery and age in the previous studies (15). Use "Candida score" based on clinical indices was introduced in 2008,by Leon and his colleagues for the first time. In 2006, a Spanish group, in a prospective and multicenter cohort of ICU patients developing hospital-acquired severe sepsis or septic shock, identified four predictors (surgery, multifocal colonization, total parenteral nutrition and severe sepsis) of proven invasive Candida infection (2). Based on these predictors, a score named "Candida score" was built. Such a score was useful to stratify the risk of Candida infection and differentiate patients who would benefit from early antifungal treatment from those for whom invasive candidiasis is highly improbable. The "Candida score" for a cut-off value of 2.5 was as follows: parenteral nutrition, 0.908; surgery, 0.997; multifocal colonization, 1.112; and severe sepsis, 2.038 in the logit model (2,3). A 'candida score' of >
2.5 was classed as a positive ‘Candida score’ which should identify patients
who would benefit from early antifungal treatment. Although candida scoring
system was successful in early diagnosis in previous studies, its potentials
should be evaluated in each community because many confounding factors such as
nutrition which are affecting patients’ life are different in societies.
Therefore we have conducted a survey on candida score comparing it with a new
scoring system named “Modified Candida Score” which is designed for ICU
patients in Masih Daneshvari hospital, Tehran, Iran to identify patients in
high risk of candida infection. It is expected that early diagnosis and
prophylaxis therapy release patients from disease and high costs of treatment. Risk
factors such as Total
Parenteral Nutrition, central
venous catheters, broad
antibiotic usage, abdominal surgery, pancreatitis, severe sepsis, ICU stay>7
days, cortico steroids therapy, immunosuppressive state, diabetes mellitus and
mechanical ventilation were examined to distinguish high risk patients. After
the risk factor assessment for “Modified Candida score”, sensitivity and
specificity of two methods were compared together.


Materials and

This was a prospective, cohort, observational study in intensive
care unit (ICU) of Masih Daneshvari hospital, from October 2012 to October
2013. All patients exhibiting, on ICU admission (medical and surgical) or
during their ICU stay (at least 7 days in ICU), hospital-acquired severe sepsis
or septic shock could be included in this study. Exclusion criteria were
community-acquired infections, age < 18 years, neutropenia defined as a total leukocyte count < 500/mm3, pregnant women and nursing mothers, and patients who were treated with antifungal drugs when severe sepsis or septic shock occurred. In total, 750 patients were entered in the study. The high risk Candida infections in patients, were determined based on the works done in previous literatures(2). The risk factors were considered for candida infection included the patients undergoing abdominal surgery, the patients treated with total parenteral nutrition (TPN), the patients treated with broad-spectrum antibiotics, the patients treated with corticosteroids and other immunosuppressive therapy, the patients in ICU for more than 7 days and the patients with acute kidney injury (AKI). Only insulin-treated patients were considered to have diabetes mellitus. Samples culture were obtained from all patients at the admission and was repeated weekly till patients' discharge. Samples were obtained from tracheal aspirates, pharyngeal exudates, blood, foley catheters and urine. Ophthalmic examination was done routinely for every patient with sepsis. Proven candidal infection required one of the following criteria: presence of candidemia, that is, documentation of one blood culture that yielded a Candida species; ophthalmic examination consistent with candidal end ophthalmitis in a patient with clinical sepsis; isolation of Candida species in sterile body fluids samples (e.g., pleural fluid, pericardial fluid) or candidal peritonitis; or histologically documented candidiasiss1 .Proven candida infected patients had received anti-fungal treatment according to their case. Finally, risk factors in "Modified Candida score" were determined using statistical models. Sensitivity and specificity of "Modified Candida score" and "Candida score" were compared together in final. All patients submitted written consent to participate, and the ethics committee of Shahid Beheshti University of Medical Sciences approved the protocol.  s1So what about other sample culture result? Why do we obtained samples from tracheal aspirates, pharyngeal exudates, blood, foley catheters and urine? Don't they have any role in diagnosis?

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