Evaluating the Prognostic Value of the EQUAL Candida Score and a Nomogram-Based Approach for Candidaemia-Related Mortality.

Abstract

Introduction: Candidaemia is a life-threatening infection with a persistently high mortality rate, despite significant advances in antifungal therapy and supportive care. The European Confederation of Medical Mycology developed the EQUAL Candida Score as a standardised tool to evaluate adherence to guideline-based management; however, its prognostic value has not been consistently demonstrated in different patient populations. This study aimed to evaluate the clinical impact of adhering to guidelines and determine the predictive value of the EQUAL Candida Score for mortality risk in candidaemia patients.

Methods: This retrospective cohort study included adult patients with candidaemia who were treated at a tertiary care hospital. Patients were classified as survivors or nonsurvivors based on 90-day candidaemia-related mortality. We identified independent predictors of mortality using multivariable Cox regression analysis and subsequently developed a prognostic nomogram based on the final model.

Results: A total of 189 patients with candidaemia were included in the study, of whom 88 (46.6%) died within 90 days. The median EQUAL Candida Score was significantly lower among nonsurvivors compared with survivors (8 vs. 13, p < 0.001). This prognostic association remained consistent in subgroup analyses, both in patients with (10 vs. 13, p < 0.001) and without (10 vs. 13, p = 0.022) central venous catheters. An optimal cut-off score of 12 was identified across all groups, yielding a sensitivity of 70%-80% and a specificity of 79%. Kaplan-Meier survival analysis further confirmed that patients with an EQUAL Score ≥ 12 had significantly higher survival rates in all subgroups. In multivariable Cox regression, immunosuppressive treatment (HR 1.728), septic shock (HR 2.035), lack of source control (HR 2.013) and an EQUAL Score < 12 (HR 3.503) were identified as independent predictors of candidaemia-related mortality. Based on these variables, a nomogram was developed to estimate individualised survival probabilities at 1, 3 and 6 months. External validation in an independent cohort (n = 64) confirmed the model's prognostic performance, with a Harrell's C-index of 0.704 (95% CI: 0.587-0.821), despite the limited sample size.

Conclusion: The EQUAL Candida Score serves as a reliable prognostic marker for candidaemia. When combined with clinical parameters, it enhances the accuracy of mortality risk estimation. Our novel nomogram provides a practical framework for early risk stratification and may optimise management strategies for high-risk patients.