Risk factors for early invasive fungal disease in critically ill patients.

Sir,

We read with immense pleasure the article on “Risk factors for early invasive fungal disease in critically ill patients” by Singh G.[1] We appreciate the authors in conducting this study in Indonesia, where the data is still scarce, but we would like to mention a few comments and queries regarding the article.

With regard to methodology why is Leon score preferred over the other scoring systems when it is clear that sensitivity and specificity of these individual scoring systems are quite variable with high negative predictive value but a poor positive predictive value.[2] Even the colonization assessment was not performed according to the study done by Leon et al.[3] Statistical analysis and sample size calculation need to be mentioned in this study. Evidence of fungal UTI based on >104 colony-forming units (CFU)/ml needs to be explained as it is still not clear to differentiate infection from colonization with candiduria which is very common in catheterized urine specimens, and only heavy (>105) colonisation should be considered as a risk factor for invasive candidiasis.[4]

With regard to diagnostics, methods used in diagnosis need to be mentioned because routine cultures have lower sensitivity and take longer when compared to automated technologies.[5] Data regarding species and their sensitivity profiles, if mentioned would have added weight to this study.

Known risk factors of invasive fungal disease (IFD) such as higher APACHE 2 scores and low BMI (malnutrition), use of blood products(as major group is of trauma and surgery), and use of broad spectrum antibiotics need to be mentioned.[6]

In India Candida tropicalis followed by Candida albicans are the most common isolates as reported by the largest multicentre study till date conducted in India, with Candida guilliermondii, an echinocandin resistant species occurring rarely.[7]

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Conflicts of interest

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