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Intra-abdominal candidiasis is as common as candidaemia and often lethal

June 01 2016

Harking back to the early days of fluconazole, Vergidis and colleagues in Pittsburgh have now reclassified intra-abdominal candidiasis (IAC) and from a retrospective study of IAC cases in adults, they  highlight that  source control intervention and prompt antifungal treatment are essential for a good outcome.

Over a 2 year period, all 163 patients who grew Candida spp from intra-abdominal sources were identified. Twenty (12%) were transplant patients and 30 (18%) were community acquired. Each patient’s disease was sub-typed as shown in the table, along with the overall 100 day mortality.

Intra-abdominal candidiasis sub-type

Source of infection  (mortality)

GI tract

Biliary tree or pancreas

Primary peritonitis

4.9% (88%)

Secondary peritonitis

27% (34%)

5.5% (67%)

Intra-abdominal abscess

36% (19%)

18% (13%)

Infected pancreatic necrosis

-

4.9% (25%)

Cholecystitis, cholangitis

-

3.1% (20%)

In the same timeframe, the authors identified 163 patients with IAC, compared to 161 with candidaemia – only 6% of the IAC cases had a positive blood culture for Candida  spp. However 67% of IAC cases also grew bacteria, typically enteric pathogens such as Enterococcus and Enterobacteriaceae – 10% of the IAC cases grew 2 or more Candida  spp.  Candida albicans  was the most common species found, with C. glabrata, the second most common species. C. glabrata  was significantly associated with multiple prior abdominal surgeries and MDR Gram-negative bacterial co-infection. Susceptibility testing was done on only 13% of isolates.

Younger patients  had better outcomes as did those with abscesses and early source control (surgical in 59% and percutaneous in 36%). In those with GI tract sources (53%), younger age, early antifungal therapy and abscess subtype were significantly associated with better outcomes.


Large retrogastric abscess attached to the posterior gastric wall of the stomach caused by Candida glabrata

Whilst some patients improved without antifungal therapy, the authors did not identify markers for those patients who will recover and those who will deteriorate. Infectious diseases (ID) consultations were obtained in only 48% of patients and this group was significantly more likely to receive antifungal therapy. Antifungal therapy, combined with source control, will be necessary in almost all cases.

This observation parallels the debates about which candidaemic patients should or should not be treated with antifungals – guidelines now recommend that all should be treated. Likewise all isolates should be antifungal- susceptibility tested. Infection specialists must be better engaged with these complex patients.

Vergidis et al PLOS ONE | DOI:10.1371/journal.pone.0153247