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A bedside scoring system Candida score for early antifungal treatment in nonneutropenic critically ill patients with C

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A bedside scoring system Candida score for early antifungal treatment in nonneutropenic critically ill patients with C

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    1. A bedside scoring system (“Candida score”) for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization Critical Care Medicine 2006; 34(2): 730-737 Cristóbal León, MD; Sergio Ruiz-Santana, MD, PhD; Pedro Saavedra, PhD; Benito Almirante, MD, PhD; Juan Nolla-Salas, MD, PhD; Francisco Álvarez-Lerma, MD, PhD; José Garnacho-Montero, MD; María Ángeles León, MD, PhD; EPCAN Study Group

    2. 95.05.15 POCLAL THE SURGICAL CLIENT

    3. 95.05.15 POCLAL Infection by Candida species Substantially increased incidence Severe sepsis, septic shock, multiorgan failure Early sign, late diagnosis 40% mortality rate

    4. 95.05.15 POCLAL Colonization v.s. Infection Prior Candida colonization ? preemptive therapy Patients admitted at ICU Colonized v.s. systemic infection (few) “Candida score” Positive surveillance culture Colonization index Preemptive antifungal therapy

    5. 95.05.15 POCLAL Methods: Study Population EPCAN project Surveillance study of fungal infection and colonization in critically ill patients 70 tertiary care hospital in Spain May 1998 ~ January 1999 7 ~ 73 days in surgical-medical ICU 1,765 patients over age 18 years

    6. 95.05.15 POCLAL Design Prospective, cohort, observational, multiple center Screening culture Admission, once a week Tracheal aspirates, pharyngeal exudates, gastric aspirates, urine Peripheral blood, intravascular line, feces, wound exudate, surgical drains, infectious foci ? physician

    7. 95.05.15 POCLAL “Candida Score” Age, gender Underlying disease Reason for ICU admission Concomitant infection Presence and duration of risk factors Antifungal therapy vital sign at discharge Neutropenia -- exclusion !

    8. 95.05.15 POCLAL Definitions Surgical, trauma, medical Severity – APACHE II DM Insulin-treated Chronic bronchitis Productive cough or expectoration for 90 days a year and for > 2 years

    9. 95.05.15 POCLAL Definitions Chronic liver disease Liver biopsy, sign of portal hypertension Esophageal varices , ascites Chronic failure HD or PD at admission Severe heart failure NYHA grade III and IV

    10. 95.05.15 POCLAL Risk Factors Arterial catheter Central venous catheter Total parental nutrition Enteral nutrition Urinary catheter Antibiotic treatment: 10 days before ICU admission Extrarenal depuration procedures Steroids 20 mg prednisolone at least 2 weeks, 30 mg at least 1 week

    11. 95.05.15 POCLAL Colonization Candida in nonsignificant samples Oropharynx, stomach, urine, tracheal aspirates Unifocal v.s. Multiple focal 2 weeks consecutive sets

    12. 95.05.15 POCLAL Candidal Infection Presence of candidemia Candidal endophthalmitis Candida in significant samples Pleural fluid, pericardial fluid

    13. 95.05.15 POCLAL Candidal Infection Candidal peritonitis Laparotomy or percutaneous puncture Hollow organ perforation, dehiscence of an intestinal suture with peritonitis, severe acute pancreatitis Catheter-related candidemia Intravascular device, one or more positive blood culture Fever, chill, and/or hypotension No apparent source of bloodstream infection Positive catheter culture, same organism (species & susceptibility)

    14. 95.05.15 POCLAL Statistical Analysis Crude Odd ratio Training set: 65% sample Logistic regression (logit) model Power Area under the receiver operating characteristics (ROC) Confidence interval Validation set: 35%

    15. 95.05.15 POCLAL Result

    16. 95.05.15 POCLAL Candidal Infection 97 patients, 5.8% Mean age 58.5 years, APACHE II 17 (10.6 ~ 30.8) 58 candidemia, 30 peritonitis, 6 endophthalmitis, 3 candidemia and peritonitis 18 catheter-related candidemia 87.6 % antifungal treatment Elapsed time: 12 (0.3 ~ 37.8) days

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    22. 95.05.15 POCLAL Discussion Candida score Multifocal colonization, TPN, Surgery, severe sepsis Differentiation Antifungal therapy

    23. 95.05.15 POCLAL Multifocal Colonization Independent risk factor National Epidemiology of Mycoses Survey (NEMIS) SICU at 6 sites in USA Rectal and/or urine surveillance Not related to bloodstream infection This study Multiple site, weekly culture

    24. 95.05.15 POCLAL Nosocomial Fungal Infection “probable”, ”possible”, ”proven Unreliable for nonneutropenic patients Colonization density: as predictor Index: positive number site / number sites cultured ?0.4, preemptive antifungal therapy 2-yr prospective & 2-yr historical control cohorts ICU candidiasis: 2.2% ? 0% Candida score: improve specificity

    25. 95.05.15 POCLAL Antifungal Therapy “Heavy” colonization ? treatment ? ICUs in France Multifocal Candida colonization Clinical signs of sepsis Several other risk factors for invasive candidiasis 79% of 135 intensivists in Spain Multifocal Candida colonization Clinical signs of sepsis

    26. 95.05.15 POCLAL Paphitou & Ostrosky Retrospective, 12 ICUS, U.S. & Brazil Prediction rule At least 1 “major” & at least 2 “minor” risk factors At 48 hours and to stay for ?2 days 10% risk of invasive candidiasis No validation Fungal colonization: not included This study: more reliable

    27. 95.05.15 POCLAL DuPont -- scoring Retrospective review in SICU Prospective follow-up in France Female, UGI origin of peritonitis, cardiovascular failure, use of antibiotics Grade C: 3 qualifiers Sensitivity 84%, specificity 50% Single center, surgical patients

    28. 95.05.15 POCLAL EPCAN Database Cohort of nonneutropenic ICU patients Low rate of proven candidiasis, high mortality Unifocal colonization (26.5%) Multifocal colonization (50.9%) Proven infection (57.7%) Colonization Key factor to start early antifungal infection

    29. 95.05.15 POCLAL Candida Score Based on previously reported risk factors Reliable differentiation Colonization & infection CVP Repeated described as major risk factor Not significant in this large prospective multicenter study

    30. 95.05.15 POCLAL Candida Score Easy-to-remember; easy daily tasks 1 for TPN, surgery & multifocal colonization; 2 for clinical severe sepsis Cut off value: 2.5 Sensitivity 81%, specificity 74% Score > 2.5 ? 7.75 times to have proven infection

    31. 95.05.15 POCLAL Candida Score More efficient selection of antifungal therapy Prevention of development of resistant species Candida score At the time of ICU admission Any time candidiasis is suspected

    32. A score > 2.5 will help intensivists select patients who will benefit from early antifungal administration.

    33. 95.05.15 POCLAL

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