Discussion This study shows that the new Candida score named “Modified candidascore” for Iranian ICU patients, allows differentiating between Candida speciescolonization and candida infection in non neutropenic ICU patients. Therefore, forprescribing antifungals, according to a Candida score >4.0, will allow moreefficient selection of patients who indeed will benefit from the increasingnumber of available antifungal drugs (17) and, at the same time, more adequateprevention of the development of new resistant species due to an excess ofinappropriate and potentially detrimental antifungal treatments (18). Cut off point value in this study was obtained 4,while in beforestudies, in special Santana study , gold standard for cutoff point was 2.5 (2,19).

Modified candida score wasassessed based on seven components containing surgeryon ICU admission, total parenteral nutrition, ICUstay>7 days, broad antibiotic,Pancreatitis, central venous catheter and severe sepsis. These seven components were found to be independentpredictors of systemic candidiasis in ICU patient population. Three components:surgery on ICU admission, total parenteral nutrition and severe sepsis wereconfirmed in before studies (2, 19-20). Severe sepsis between components, hadthe highest weight in modified candida score structure. Accordingly, it ispossible to stratify the risk of proven candida infection in a large populationof critically ill patients and to select those patients who will most benefitfrom starting antifungal therapy (i.e.

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, early antifungal administration givento patients with evidence of colonization in the presence of multiple riskfactors for candidal infection). Sensitivity and specificity in modified candida scorewere suitable values 0.83 and 0.80 respectively. Candida score introduced bySantana (2001), also was used to candida diagnosis in studied sample.

Sensitivitycomparison test did not show significant difference between two scoringsystems, but modified candida score specificity was higher than candida score,substantially.Sensitivity and specificity in candida score wereobtained 0.81 and 0.

73 respectively, therefore with low specificity for examplea patient with severe sepsis and one other risk factor such as total parenteralnutrition, surgery will have to take antifungal usage  that this is not satisfactory. Ina multicenter retrospective study conducted by Ostrosky (2008), a predictionmodel for nosocomial invasive candidiasis in the intensive care setting wassupposed with very low sensitivity34%, specificity of 90% and negativepredictive value of 97%. DuPont and co-workers (20) carried out a retrospectivesystematic review of surgical intensive care patients. A scoring system wasproposed with the following risk factors: female gender, upper gastrointestinalorigin of peritonitis, cardiovascular failure, and use of antibiotics. A gradeC score, defined as the presence of three qualifiers, was associated with asensitivity of 84% and specificity of 50 % for the detection of yeasts in theperitoneal fluid of patients with peritonitis (22).Based on the IDSA guideline 2016, forpatients with suspected HAP/VAP, it has been recommend using clinical criteriaalone, rather than using serum procalcytonin (PCT) plusclinical criteria, to decide whether or not to initiate antibiotic therapy.

PCT ispotentially useful in the diagnosis of infection, as well as in the assessmentof response to antibiotic therapy2. In several randomized, controlled trials,including adult critically ill patients, PCT guidance was repeatedly associatedwith a decrease in the duration of antibiotic therapy. But we didn’tremove the PCT fromthe decision-making process to stop prescribing antibiotics in this study 23.Assessmentwith the Candida score should be performed at the time of ICU admission and anytime candidiasis is suspected. The medical literature is flooded withcomplicated prediction rules and scores (23–24), and there is a need to haveavailable bedside easy-to-remember scores that would make daily tasks easierfor clinicians. The strong points of this study were sufficient sample size, aconsiderable number of risk factors and the investigation both of the surgicaland medical ICU patients. A few numbers of abdominal surgery operations and highfrequency of pulmonary patients, were the weaknesses of this research. It isrecommended to conduct a multicenter study.

Recently it has been defined newcriteria such as qSOFA instead of SOFA to in hospital mortality prediction (26-31). ConclusionsA new score with high specificity, the Modified Candida Score,which was calculated according to data collected in intensive care unit ofMasih Daneshvari hospital, Iran, is an easy-to-remember bedside predictionrule. A score >4 will help intensivists select patients who will benefitfrom early antifungal administration.