in a previous edition of critical care , shorr and colleagues developed a simple weight risk score for identifying patients with candidemia upon hospital admission . using recursive partitioning , they determined the best discriminators of candida bloodstream infections in patients upon hospitalization ( identified as a positive blood culture 1 day prior to or 2 days after admission ) by retrospectively reviewing the carefusion outcomes research database , comprising 64,109 bloodstream infection cases admitted to 176 acute care hospitals from 2000 to 2005 . three sets of models were applied ( equal weight , unequal weight , and full weight with additional variables ) for sensitivity analysis . the risk score was then validated using the 2006/2007 year cohort for a total of 24,685 bloodstream infections . the rate of candidemia was 1.2% of all bloodstream infections for the 5-year derivation cohort , and was 1.3% for the validation cohort . the rate was increased to 2.3% and 3.1% , respectively , for those patients with mechanical ventilation . baseline characteristics were largely similar between both cohorts , and univariate analysis determined that the following risk factors are associated with candidemia : age 64 years ; cachexia ; deranged albumin , arterial ph , and electrolytes ; temperature 98c or fever ; altered mental status ; previous hospitalization within 30 days ; admission from another healthcare facility ; and mechanical ventilation . recursive partitioning revealed that the six best discriminators are age < 64 years , temperature < 98c , cachexia , previous hospitalization , admission from another healthcare facility , and mechanical ventilation . in the derivation cohort , those patients with one risk factor had a rate of candidemia of 0.4% while those with all six risk factors had a rate of 27.3% . in the validation cohort , the area under the receiver operating curve for the risk score was 0.70 for the derivation cohort and was 0.71 for the validation cohort . with the model involving six risk factors , the area under the receiver operating curve was similar in both cohorts . finally , the area under the receiver operating curve for the model with 16 risk factors was associated with a slightly higher discrimination in both cohorts ; but on recalibration with the validation cohort , seven risk variables were deemed poor discriminators - thus suggesting that additional factors did not improve the risk model during validation . even though the rates of candidemia bloodstream infections on admission are low , the authors conclude that with certain epidemiologic risk factors the rates increase from 1 in 500 to 1 in 4 bloodstream infection admissions . a validated risk model based on these six discriminators ( age < 64 years , temperature < 98c , cachexia , previous hospitalization , admission from another healthcare facility , and mechanical ventilation ) may therefore provide early detection and subsequent early appropriate treatment of these high - risk patients , potentially improving outcome . candidemia is the fourth most common bloodstream isolate in hospitalized patients and accounts for an increased length of stay and significant morbidity and mortality , ranging from 25 to 58% [ 2 - 4 ] . many of these data have been evaluated in hospitalized patients , however , where the epidemiologic data and risk factor analysis have been more developed . other predictive scores have included candida colonization , parenteral nutrition , and antibacterial therapy - these factors are common in hospitalized intensive care unit patients , which constitute most cases of candidemia . early - onset candidemia , as defined by a positive blood culture within 2 days of admission , is a less described entity . shorr and colleagues , in another publication , have recently outlined the burden of early - onset candidemia , with a longer length of stay , higher crude mortality , and higher hospitalization cost when compared with bacterial bloodstream infections . while the rates of candidemia remain low ( 1.3% of all bacteremia cases ) , certain high - risk patients have much higher rates approaching 27% as outlined in this study . risk stratification by application of the validated risk model can have a profound impact on early therapy and intervention in these cases . the role of early appropriate therapy has become important as inappropriate or delayed therapy leads to higher mortality [ 8 - 10 ] . in bacterial bloodstream infections and pneumonia , early identification of those at risk for multidrug - resistant organisms can lead to early appropriate therapy , and thus to a lower mortality . in candidemia , studies have show that delayed therapy can lead to a higher mortality in hospitalized patients with late candidemia . since early - onset candidemia is an unusual presentation on hospitalization , a high potential for delayed therapy exists - even in the high - risk groups . while diagnostic biomarkers ( -d - glucan ) have promise , blood cultures still remain the gold standard for diagnosis but take 24 to 72 hours for growth . risk analysis models or scores have been used in the past for prophylaxis or empiric therapy for candidemia . these scores have been in hospitalized patient populations , however , largely in the intensive care unit where candidemia is more prevalent . the use of recursive partitioning for development of risk determinants has been used in prior bacterial bloodstream infections in pediatric patients , but this is its first use in candidemia of any kind . the development of a risk model as described by shorr and colleagues therefore becomes a useful tool in determining the highest risk individuals for early - onset candidemia , thereby allowing early appropriate empiric therapy for this subset of patients . as we have evolved over the past decade to recognize and treat high - risk individuals for multidrug - resistant pneumonia ( for example , healthcare - associated pneumonia ) , shorr and colleagues ' risk model allows for that initial discrimination of the high - risk groups . for the next step we need to evaluate its impact in prospective studies , particularly evaluating various risk models and the impact on early appropriate therapy , morbidity , mortality , and candida resistance patterns . a risk model for early - onset candidemia , however , is a starting point .
bloodstream infections from candida species are associated with an increased length of stay , increased hospital costs , and higher mortality when compared with bacterial bloodstream infections . delayed or inappropriate therapy in candidemia leads to increased mortality , thus early recognition becomes paramount . with biomarkers showing promise , 
 blood cultures still remain the gold standard but require 24 to 72 hours for growth . 
 the reliance on epidemiologic risk factors for the initiation of empiric antifungal therapy therefore provides the best method for early appropriate therapy . 
 shorr and colleagues have devised a risk score to identify patients with early - onset candidemia as defined by positive blood cultures within 2 days of admission , thus allowing for the initiation of early appropriate antifungal therapy .