Development and validation of the AURIS score for predicting candidaemia in Candidozyma auris-colonised patients in the intensive care unit: a bicentric retrospective cohort study

Abstract

Background: Candidozyma auris is an emerging multidrug-resistant pathogen that frequently colonises hospitalised patients and can cause invasive disease. Traditional tools, such as the Candida score, perform poorly in this setting. We aimed to externally validate and refine a clinical prediction model for C auris candidaemia among colonised patients in the intensive care unit (ICU). Methods: We performed a retrospective analysis of prospectively and systematically collected cohort data from ICUs in two tertiary-care hospitals in Valencia, Spain, to predict candidaemia among adult C auris-colonised patients during prolonged outbreaks (October, 2017, to March, 2020). A previously derived logistic regression-based prediction model was externally validated, then refined in a bicentric cohort using Elastic Net regression. Internal validation was performed by bootstrap resampling (n=5000). Model discrimination and calibration were assessed and compared with the Candida score. Findings: In the external validation cohort, 216 C auris-colonised ICU patients were included, of whom 31 (14%) developed candidaemia. After pooling this cohort with the original derivation cohort, a bicentric dataset of 422 patients was obtained, with 68 (16%) candidaemia events. Four predictors were retained: total parenteral nutrition (TPN; p<0·0001), previous antifungal therapy (p=0·027), multifocal colonisation (p=0·0020), and urinary isolation (p=0·029). These formed a simplified four-variable model (AURIS score) with a validated area under the curve of 0·81, outperforming the Candida score (0·75; p=0·0003). A graphical nomogram and point-based score for bedside risk estimation was created. At a 28% threshold, sensitivity was 0·72, specificity 0·84, and negative predictive value 0·94. Interpretation: The AURIS score provides a pragmatic tool for risk stratification among C auris-colonised ICU patients, with value in identifying those at low risk of candidaemia, reducing unnecessary empirical antifungal therapy. Its predictors highlight the risk in multi-colonised carriers, the relevance of urinary colonisation, the ecological advantage from previous antifungal exposure, and the strong association with TPN. Broader validation across diverse clades and epidemiological settings is warranted before widespread implementation. Funding: None. Translation: For the Spanish translation of the abstract see Supplementary Materials section.