Discussion

 

This study shows that the new Candida score named “Modified candida
score” for Iranian ICU patients, allows differentiating between Candida species
colonization and candida infection in non neutropenic ICU patients. Therefore, for
prescribing antifungals, according to a Candida score >4.0, will allow more
efficient selection of patients who indeed will benefit from the increasing
number of available antifungal drugs (17) and, at the same time, more adequate
prevention of the development of new resistant species due to an excess of
inappropriate and potentially detrimental antifungal treatments (18).

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Cut off point value in this study was obtained 4,while in before
studies, in special Santana study , gold standard for cutoff point was 2.5 (2,19).Modified candida score was
assessed based on seven components containing surgery
on ICU admission, total parenteral nutrition, ICU
stay>7 days, broad antibiotic,
Pancreatitis, central venous catheter and severe sepsis. These seven components were found to be independent
predictors of systemic candidiasis in ICU patient population. Three components:
surgery on ICU admission, total parenteral nutrition and severe sepsis were
confirmed in before studies (2, 19-20). Severe sepsis between components, had
the highest weight in modified candida score structure. Accordingly, it is
possible to stratify the risk of proven candida infection in a large population
of critically ill patients and to select those patients who will most benefit
from starting antifungal therapy (i.e., early antifungal administration given
to patients with evidence of colonization in the presence of multiple risk
factors for candidal infection).

Sensitivity and specificity in modified candida score
were suitable values 0.83 and 0.80 respectively. Candida score introduced by
Santana (2001), also was used to candida diagnosis in studied sample. Sensitivity
comparison test did not show significant difference between two scoring
systems, but modified candida score specificity was higher than candida score,
substantially.

Sensitivity and specificity in candida score were
obtained 0.81 and 0.73 respectively, therefore with low specificity for example
a patient with severe sepsis and one other risk factor such as total parenteral
nutrition, surgery will have to take antifungal usage  that this is not satisfactory.

 

In
a multicenter retrospective study conducted by Ostrosky (2008), a prediction
model for nosocomial invasive candidiasis in the intensive care setting was
supposed with very low sensitivity34%, specificity of 90% and negative
predictive value of 97%. DuPont and co-workers (20) carried out a retrospective
systematic review of surgical intensive care patients. A scoring system was
proposed with the following risk factors: female gender, upper gastrointestinal
origin of peritonitis, cardiovascular failure, and use of antibiotics. A grade
C score, defined as the presence of three qualifiers, was associated with a
sensitivity of 84% and specificity of 50 % for the detection of yeasts in the
peritoneal fluid of patients with peritonitis (22).

Based on the IDSA guideline 2016, for
patients with suspected HAP/VAP, it has been recommend using clinical criteria
alone, rather than using serum procalcytonin (PCT) plus
clinical criteria, to decide whether or not to initiate antibiotic therapy. PCT is
potentially useful in the diagnosis of infection, as well as in the assessment
of response to antibiotic therapy2. In several randomized, controlled trials,
including adult critically ill patients, PCT guidance was repeatedly associated
with a decrease in the duration of antibiotic therapy. But we didn’t
remove the PCT from
the decision-making process to stop prescribing antibiotics in this study 23.

Assessment
with the Candida score should be performed at the time of ICU admission and any
time candidiasis is suspected. The medical literature is flooded with
complicated prediction rules and scores (23–24), and there is a need to have
available bedside easy-to-remember scores that would make daily tasks easier
for clinicians. The strong points of this study were sufficient sample size, a
considerable number of risk factors and the investigation both of the surgical
and medical ICU patients. A few numbers of abdominal surgery operations and high
frequency of pulmonary patients, were the weaknesses of this research. It is
recommended to conduct a multicenter study. Recently it has been defined new
criteria such as qSOFA instead of SOFA to in hospital mortality prediction (26-31).

 

Conclusions

A new score with high specificity, the Modified Candida Score,
which was calculated according to data collected in intensive care unit of
Masih Daneshvari hospital, Iran, is an easy-to-remember bedside prediction
rule. A score >4 will help intensivists select patients who will benefit
from early antifungal administration.