There were 213 ICU admissions with SAP during the study period. There were 32
re-admissions of 26 patients during the same hospital stay. Seventy-six patients were
excluded as they were directly transferred to the ICU from other hospitals. Four
patients already had established candidal infection on admission to ICU and were
excluded from further analysis (Figure ). Therefore, 101 patients
were included of whom 58 (57%) were men. The median (IQR) age was 60 (50 to 73) years,
and the most common causes of SAP were gallstones (45 (44.6%)) and alcohol (30 (29.7%)
Consort diagram for recruitment of patients.
Baseline clinical data from all patients
There was no significant difference in APACHE II scores between the two groups. Eighteen
(17.8%) patients developed ICI. Patients with ICI had a longer median length of ICU stay
(16.9 versus 7.3 days, P = 0.0043). There was a significant association between
open necrosectomy and subsequent ICI (Table , P =
0.0171) on univariate analysis, but this was not significant in regression analysis.
Overall, 18 (17.8%) patients died in ICU with a higher mortality in patients with ICI
(5/18 (27.8%) versus 13/83 (15.7%)). Overall hospital mortality was 29.7% (30/101) which
was significantly higher in patients who developed ICI: 10/18 patients (55.6%) died,
compared to 20 deaths in 83 patients without ICI (24.1%) (P = 0.0201) (Table
Table displays the risk factors for development of ICI for those
patients with and without ICI. There were no significant differences in incidence of
severe sepsis, or use of CVC lines, antibiotics, RRT, steroids, immunosuppressive
therapy, previous surgery or TPN between the two groups. Of the known risk factors, only
colonisation with Candida spp. was significantly greater in the ICI group.
Sixteen (88.9%) patients with invasive candida infection were colonised with candida, as
opposed to 37 (44.6%) without subsequent infection (P = 0.0006) (Table ). Using logistic regression analysis, colonisation with candida (OR
4.33) was the only factor significantly associated with invasive candidal infection
Risk factors for the development of invasive candidal infection
Multivariate logistic regression analysis of risk factors for ICI for patients
with SAP admitted to ICU
Eighteen patients developed ICI, giving an infection rate of 13.2 per 1,000 days
(18/1,359 days). Candidaemia was present in 5 (27.8%) infected patients (3.7 per
1,000 days). Five patients had only candidaemia, whereas three patients with
candidaemia also had either tissue or abdominal fluid samples that were positive for
candida spp. Candida spp. were isolated in pancreatic tissue in
four patients. Ten patients had Candida in abdominal drain fluid samples
only and received antifungal medication.
Candida species isolated
In the patients with a positive blood or tissue culture, C. albicans was
isolated in seven patients, C. glabrata and C. lusitaniae each in
one patient and C. albicans and C. glabrata in one patient. In patients who
had a positive drain fluid culture and subsequent antifungal therapy, there were
three patients with C. albicans, two with C. glabrata and one each
with C. parapsilosis and C. lusitaniae. One sample contained a
mixed growth of C. albicans and C. parapsilosis (Figure and ).
Figure 2 Candidal species isolated. (a) The number of candidal species
isolated from patients. The left hand bar shows the contribution of candidal
species isolated from patients, including mixed growth; the right hand bar
shows single isolates only. (b) The proportion (more ...)
Candida risk scores
Data regarding colonisation screening were not available for six patients and so
these were excluded from analysis of the performance of the CCIS. The risk prediction
scores tested demonstrated low sensitivities, with values below 0.7 (Table ). The Candida Score had the highest specificity of 0.85 and the
CCIS had a specificity of 0.79. All scoring systems had high NPVs (>0.7). PPVs were
all below 0.5. The CCIS demonstrated a LR + of 3.2 and the other scores tested had
lower LR + values. No scores had LR - below 0.1.
Comparison of the diagnostic accuracy and discrimination of the Candida score,
Modified Invasive Candidiasis Score and Candida Colonisation Index score in
The CCIS had the best discrimination of the scores tested, with AUROC of 0.79 (Figure
). The other two scores demonstrated poor discrimination,
with AUROCs less than 0.7.
AUROC for discrimination of the Candida Colonisation Index score with 95%
confidence intervals (dotted lines).