Intra-Abdominal Candidiasis, Candida peritonitis Paschalis Vergidis, MD, MSc Infectious Diseases Consultant Manchester University NHS Foundation Trust Learning Objectives To understand the different forms of intra-abdominal candidiasis To
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Intra-Abdominal Candidiasis, Candida peritonitis Paschalis Vergidis, MD, MSc
Infectious Diseases Consultant
Manchester University NHS Foundation Trust<br>
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Learning Objectives To understand the different forms of intra-abdominal candidiasis To discuss the risk factors for intra-abdominal candidiasis To review the management and outcomes of intra-abdominal candidiasis<br>
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Kullberg BJ, Arendrup M. NEJM 2015; 373: 1445-1456 Spectrum of Disease<br>
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Intra-Abdominal Candidiasis Common form of deep-seated candidiasis
Poorly studied compared to candidaemia
Accounts for ~10% of all cases of peritonitis
Bacterial co-infection is common<br>
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Classification Primary peritonitis
No apparent breach of the GI tract
Secondary Peritonitis
Follows perforations, surgical leaks, trauma or other pathological process
Tertiary Peritonitis
Persistence or recurrence of intra-abdominal infection following treatment
Intra-Abdominal Abscess
Localized infection resulting from pathological process or breach of the GI tract
Infected Pancreatic Necrosis
Infection of the non-vitalized pancreatic tissue
Cholecystitis, cholangitis Vergidis et al. PLoS ONE. 2016; 11(4). e0153247<br>
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Risk factors Recurrent GI surgery
GI tract perforations
GI anastomosis leakage
Prolonged broad-spectrum antibiotics
Acute renal failure
Total parenteral nutrition
ICU stay
Diabetes mellitus
Immunosuppression Acquisition can be:
Community-acquired
Hospital-acquired
Healthcare-associated Bassetti et al. Intensive Care Med. 2013; 39(12): 2092-106<br>
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Microbiology Candida albicans (65-82%)
C. glabrata <20%
C. tropicalis <10%
C. parapsilosis <5%
Other non-albicans Candida spp. ~2%
Mixed Candida spp. ~5%<br>
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Clinical manifestations Fever
Abdominal pain (+/- guarding/rebound tenderness)
Nausea, vomiting
Purulent discharge from abdominal drains Leucocytosis
Electrolyte abnormalities
Hypokalaemia, hypernatremia
Acidosis
Raised inflammatory markers Clinical presentation is similar to bacterial peritonitis
Bacterial co-infection is common<br>
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Diagnosis Direct microscopy
Intra-operative peritoneal or abscess fluid
Culture
Peritoneal or abscess fluid
Blood culture
In situ drains
Dialysis effluent Non-culture based diagnostics
Serum β-D-Glucan
Candida PCR<br>
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Treatment Source control
Drainage of abscesses/collections
Repair of anatomical defects
Antifungals
Antifungal treatment has been shown to improve outcomes
Echinocandin
Fluconazole (if not critically ill) Prophylaxis
Fluconazole in high-risk surgical patients Dupont et al. Arch Surg. 2002. 137 (12):134-6
Montravers et al . Crit Care Med. 2006; 34 (3): 646-52
Vergidis et al. PLoS ONE. 2016; 11(4). e0153247<br>
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Source control Drainage
Percutaneous (CT-, ultrasound-guided)
Transgastric
Surgical procedures
Laparotomy to repair anatomical defects<br>
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Prognosis Early source control and antifungal treatment are associated with improved outcomes
Mortality ~30% in recent studies
Mortality higher in patients admitted to the ICU Vergidis et al. PLoS ONE. 2016;11(4): e0153247 Survival analysis by type of intra-abdominal candidiasis<br>
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Predictors of mortality *Acute Physiology and Chronic Health Evaluation II Dupont et al. Arch Surg. 2002; 137 (12):134-6
Montravers et al . Crit Care Med. 2006; 34 (3): 646-52
Vergidis et al. PLoS ONE. 2016; 11(4). e0153247 Increased likelihood for survival: Upper GI tract source Nosocomial peritonitis Inadequate source control Septic shock High APACHE II* Score Presence of abscess Antifungal therapy<br>
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Summary Intra-abdominal candidiasis is as common as Candida bloodstream infections Mortality rates are comparable to that of candidaemia Early source control and antifungal treatment are associated with improved outcomes<br>
