Prognostic value of the Candida score for predicting mortality in neonatal candidiasis

Background: Neonatal candidiasis remains a major cause of morbidity and mortality, particularly in low- and middle-income countries (LMICs) where access to early fungal diagnostics is limited. Despite advances in antifungal therapy, outcomes remain poor due to delayed recognition and treatment initiation. The Candida Score, originally developed for adult intensive care populations, may provide a simple, bedside prognostic tool when adapted for neonatal care. Objectives: The aim of this study was to evaluate the prognostic utility of the Candida Score in predicting 28-day mortality among neonates with culture-proven candidiasis. Methods: This retrospective cohort study included neonates with positive Candida blood cultures admitted to two tertiary NICUs in Indonesia from January 2020 to December 2023. The Candida Score—comprising four equally weighted components (severe sepsis, surgery, total parenteral nutrition, and multifocal Candida colonization)—was calculated retrospectively according to the criteria of León et al. Survival probabilities were estimated using Kaplan–Meier and log-rank tests, and predictors of mortality were identified using Cox proportional hazards regression adjusted for key covariates. The proportional hazards assumption was verified using log-minus-log plots and Schoenfeld residuals. Results: A total of 76 neonates met the inclusion criteria. Overall, 28-day mortality was 48.7%, with most deaths occurring within the first week after diagnosis. A Candida Score ≥ 3 was independently associated with a twelve-fold increased risk of death (hazard ratio 12.0; 95% CI: 2.9–50.2; p = 0.001). Thrombocytopenia also emerged as a significant secondary predictor of poor outcome, reinforcing its potential role in refining risk assessment. Conclusions: A Candida Score ≥ 3 is a strong prognostic indicator of 28-day mortality in neonatal candidiasis. Integrating this simple and low-cost scoring system into neonatal sepsis management may help clinicians identify high-risk infants earlier and optimize antifungal intervention, particularly in resource-limited settings.