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Problematic dichotomisation of risk for ICU-acquired invasive candidiasis: results using a risk predictive model to categorise three levels of risk from a multicentre prospective cohort of Australian ICU patients

  1. Tania C. Sorrell13
  1. 1Infection Management Services. Princess Alexandra Hospital, Brisbane, Australia, School of Medicine, University of Queensland, Brisbane, Australia
  2. 2Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Australia, The University of Queensland, Brisbane, Australia
  3. 3Psychology Department, Macquarie University, Sydney, Australia
  4. 4Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Westmead, Australia, Current address: Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, USA
  5. 5Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Westmead, Australia
  6. 6Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, Westmead Hospital, Sydney, Australia, Sydney Medical School, University of Sydney, Sydney, Australia
  7. 7Department of Microbiology and Infectious Diseases, St Vincent's Hospital, Sydney, Australia
  8. 8Department of Intensive Care Medicine, Nepean Hospital, University of Sydney, Sydney, Australia
  9. 9Department of Microbiology and Infectious Diseases, Concord Hospital, Sydney, Australia
  10. 10Department of Intensive Care Medicine, Concord Hospital, Sydney, Australia
  11. 11Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Sydney, Australia, Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
  12. 12Victorian Infectious Diseases Service, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia, Current address: Australian Institute of Tropical Medicine and Hygiene, James Cook University, Townsville, Australia
  13. 13Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia, Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Sydney, Australia
  1. Corresponding author: Tania C Sorrell, Marie Bashir Institute, Level 4 Westmead Institute for Medical Research, 196 Hawkesbury Rd, Westmead, NSW 2145, Australia, Tel: +61-2-86273402, Fax: +61-2-98915317, Email: tania.sorrell{at}sydney.edu.au

Abstract

Background. Delayed antifungal therapy for invasive candidiasis (IC) contributes to poor outcomes. Predictive risk models may allow targeted antifungal prophylaxis to those at greatest risk.

Methods. A prospective cohort study of 6,685 consecutive non-neutropenic patients admitted to seven Australian ICUs ≥72 hours was performed. Clinical risk factors for IC occurring prior to and following ICU admission, colonisation with Candida spp on surveillance cultures from three sites assessed twice-weekly, and the occurrence of IC ≥72 hours following ICU admission or ≤72 hours following ICU discharge were measured. From these parameters, a risk predictive model for the development of ICU-acquired IC was then derived.

Results. Ninety-six patients (1.43%) developed ICU-acquired IC. A simple summation risk predictive model using the ten independently significant variables associated with IC demonstrated overall moderate accuracy (area under receiver operator curve, 0.81). No single threshold score could categorise patients into clinically useful high- and low-risk groups. However, using two threshold scores, three patient cohorts could be identified; those at high risk (score ≥6, 4.8% of total cohort, positive predictive value, 11.7%), those at low risk (score ≤2, 43.1%, 0.24%), and those at intermediate risk (score 3-5, 52.1%, 1.46%).

Conclusions. Dichotomisation of ICU patients into high- and low-risk groups for IC risk is problematic. Categorising patients into high, intermediate, and low risk groups may more efficiently target early antifungal strategies and utilisation of newer diagnostic tests.

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