Candidemia on presentation to the hospital: development and validation of a risk score

INTRODUCTION: Candidemia results in substantial morbidity and mortality, especially if initial antifungal therapy is delayed or is inappropriate; however, candidemia is difficult to diagnose because of its nonspecific presentation. METHODS: To develop a risk score for identifying hospitalized patients with candidemia, we performed a retrospective analysis of a large database of 176 acute-care hospitals in the United States. We studied 64,019 patients with bloodstream infection (BSI) on presentation from 2000 through 2005 (derivation cohort) and 24,685 from 2006 to 2007 (validation cohort). We used recursive partitioning (RPART) to identify the best discriminators for Candida as the cause of BSI. We compared three sets of models (equal-weight, unequal-weight, vs full model with additional variables from logistic regression model) for sensitivity analysis. RESULTS: The RPART identified 6 variables as the best discriminators: age < 65 years, temperature ≤ 98°F or severe altered mental status, cachexia, previous hospitalization within 30 days, admitted from other healthcare facility, and need for mechanical ventilation. The prevalence for patients presented with 0 through 6 risk factors in the derivation cohort was 28.7%, 38.8%, 21.8%, 8.3%, 2.1%, 0.3%, and < 0.1% respectively. The corresponding candidemia rates were 0.4% (69/18,355), 0.8% (196/24,811), 1.6% (229/13,984), 3.2% (168/5,330), 4.2% (58/1,371), 9.6% (15/157), and 27.3% (3/11) respectively (P < 0.0001). Findings were similar in the validation cohort (P < 0.0001). The equal-weight risk score model, which signed 1 point to each risk factor, yielded good discrimination in both cohorts with areas under the receiver operating curve (AUROCs) of 0.70 versus 0.71 (derivation versus validation). AUROC values were similar for the unequal-weight model, which signed different weight to each risk factor based on multivariable logistic regression coefficient, (AUROCs, 0.70-0.72). Both equal-weight and unequal-weight models were well calibrated (all Hosmer-Lemshow P > 0.10, indicating predicted and observed candidemia rates did not differ significant across the 7 risk stratus). The full model with 16 risk factors had slightly higher AUROCs (0.74 versus 0.73 for derivation versus validation); however, 7 variables were no longer significant in the recalibrated model for the validation cohort, indicating that the additional items did not materially enhance the model. CONCLUSIONS: A simple equal-weight risk score differentiated patients' risk for candidemia in a graded fashion upon hospital presentation.