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Fungal Infections

 

Disease name and synonyms

 Intra-abdominal  candidiasis (Candida peritonitis)

Fungi responsible (links to these)

Candida spp., particularly C. albicans.

Disease description

Patients either develop intra-abdominal candidiasis after abdominal surgery pancreatitis or other intra-abdominal sepsis or as a complication of peritoneal dialysis. The symptoms are indistinguishable from those of bacterial peritonitis, and bacterial and intra-abdominal candidiasis may occur together. Intra-abdominal candidiasis may present as tertiary peritonitis, defined as the persistence or recurrence of intra-abdominal infection following apparently adequate therapy of primary or secondary peritonitis or as a localized intra-abdominal abscess.  Abdominal discomfort, continuing purulent discharge from an abdominal drain, fever, raised inflammatory markers and white blood cell count are all common features, although often milder than bacterial peritonitis. In those receiving peritoneal dialysis, cloudy bags are typical and may be first sign of infection. Post-surgery, Candida peritonitis is most common if the bowel has been perforated, especially following faecal peritonitis, or following anastomotic leakage. Other risk factors include multiple antibiotics and diabetes mellitus. Necrotic pancreatitis is another commoner cause.

Classification

  • Primary peritonitis
  • Intra-abdominal abscess stemmimg from a GI tract peritoneal Candida infection from a pathological tract source
  • Secondary peritonitis stemming from a GI Peritoneal Candida infection resulting from a pathologic tract source
  • Intra-abdominal abscess stemming from a GI tract source
  • Secondary peritonitis stemming from a hepatobiliary or pancreatic source
  • Intra-abdominal abscess stemming from a hepatobiliary or pancreatic source
  • infected pancreatic necrosis
  • Cholecystitis, cholangitis

Frequency and global burden

The frequency of post-surgical intra-abdominal candidiasis is not known and is difficult to estimate. In a large multicentre study in 101 French intensive care units (ICU), hospital-acquired intra-abdominal candidiasis was documented in 73 patients over 8 months, compared with 123 patients with candidaemia without Candida peritonitis; 26 patients had both. Assuming this is generalisable to other populations, this suggests a ratio of 1 patient with hospital-acquired (almost all post-operative) Candida peritonitis for every 2 patients with candidaemia, in ICU. As between 30 and 50% of candidaemia cases occur in ICU, and there are about 300,000 episodes of candidaemia globally, this suggests about 50,000 -75,000 cases of Candida peritonitis each year.

In those with end stage renal disease worldwide (~1.7M) chronic ambulatory peritoneal dialysis (CAPD) is used in about 50%. Patients get 1 infection per 18 months on average and ~0.05 episodes per patient year are attributable to Candida spp., equivalent to ~42,500 cases annually.

Underlying problems and at risk patients

Post-surgery, Candida peritonitis is most common if the bowel has been perforated, especially following faecal peritonitis, or following anastomotic leakage. Other risk factors include multiple antibiotics and diabetes mellitus.

In CAPD peritonitis, patients with Candida peritonitis had been on peritoneal dialysis for longer, usually had prior episodes of bacterial peritonitis for which they were treated with antibacterial therapy.

Diagnostic testing

In surgical patients, Candida peritonitis is diagnosed by observing yeast microscopically or having a positive culture for Candida of the peritoneal fluid collected during operation, or sterile aspiration. The suspicion of Candida peritonitis should be raised if Candida is grown from a drain in situ. Some patients have candidaemia at the same time. About 65% of patients with Candida peritonitis also grown bacteria from their peritoneal or abscess fluid. Usually a single species of Candida is grown, but sometimes more than one; C. albicans is found in ~55% of cases.

In CAPD Candida peritonitis, Candida alone is usually cultured from the cloudy bag fluid, with many different species cultured.

Candida PCR on blood or peritoneal fluid and/or serum beta 1,3 glucan detection is likely to be diagnostic, but has not been well studied.

Treatments

In post-surgical Candida peritonitis, drainage of any abscess either surgically or percutaneously is important. Antifungal therapy with an echinocandin (caspofungin, micafungin or anidulafungin) or, if the causative organism is susceptible, fluconazole is critical. In a recent French study, 20% of the isolates were fluconazole resistant. As many patients also have concomitant bacterial peritonitis, this should also be treated.

In CAPD Candida peritonitis, a key success factor is early removal of the peritoneal catheter (PD) and return of the patient to haemodialysis. Fluconazole, an echinocandin or intravenous amphotericin B (sometimes with flucytosine) are the best treatment options.

Prophylaxis with fluconazole reduced the occurrence of Candida peritonitis in at-risk surgical patients in randomized controlled trials. Use of prophylactic oral fluconazole in patients with bacterial peritonitis complicating CAPD, at the same time as antibiotics, prevented secondary fungal peritonitis in a randomized controlled study.

Candida peritonitis Treatment Guidelines , also in Portugese, French and Mandarin.

Outlook and prognosis

In the 1990’s, the attributable mortality of post-surgical Candida peritonitis is ~37% with a ~57% overall mortality, but a recent French study indicates that the overall mortality has fallen to ~40%. In CAPD Candida peritonitis, early PD catheter removal (24 hours) results in a large reduction in mortality from 32% to 13%.

Article:  Vergidis et al 2016

Images

Large retrogastric abscess attached to the posterior gastric wall of the stomach caused by Candida glabrata. The patient had had several prior laparotomies and attacks of intra-abdominal sepsis and prior duodenojejenual anastomosis, with complicating uretero-enteric fistula Two years this was repaired, but a month post-operatively she became septic. Blood cultures grew Pseudomonas. A CT scan showed this collection (9 x 2.5cm) behind the stomach and another in the pelvis (6cm). The percutaneous drain inserted into the abscess grew only Candida glabrata.

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