A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts

• Published in: Intensive care medicine 2013-12, Vol.39 (12), p.2092-2106
• Main Authors: Bassetti, Matteo, Marchetti, Monia, Chakrabarti, Arunaloke, Colizza, Sergio, Garnacho-Montero, Jose, Kett, Daniel H., Munoz, Patricia, Cristini, Francesco, Andoniadou, Anastasia, Viale, Pierluigi, Rocca, Giorgio Della, Roilides, Emmanuel, Sganga, Gabriele, Walsh, Thomas J., Tascini, Carlo, Tumbarello, Mario, Menichetti, Francesco, Righi, Elda, Eckmann, Christian, Viscoli, Claudio, Shorr, Andrew F., Leroy, Olivier, Petrikos, George, De Rosa, Francesco Giuseppe
• Format: Article
• Language: English
• Subjects: Abdomen; Abdominal Abscess - drug therapy; Abdominal Abscess - microbiology; Abdominal surgery; Adult; Amphotericin B; Anesthesiology; Antifungal Agents - therapeutic use; Antiparasitic agents; Bacteriological Techniques; Candida - isolation & purification; Candidiasis; Candidiasis - drug therapy; Candidiasis - microbiology; Chemotherapy; Communicable diseases; Critical Care Medicine; DNA, Fungal - analysis; Emergency Medicine; Fluconazole; Health aspects; Hospitals; Humans; Infections; Infectious diseases; Intensive; Intensive care; Intraabdominal Infections - drug therapy; Intraabdominal Infections - microbiology; Medical colleges; Medicine; Medicine & Public Health; Mortality; Mycological Typing Techniques; Original; Pain Medicine; Pediatrics; Peritoneal Diseases - drug therapy; Peritoneal Diseases - microbiology; Peritonitis; Pneumology/Respiratory System; Polymerase Chain Reaction; Risk Factors; Surgical anastomosis; Thoracic surgery
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-013-3109-3

Introduction intra-abdominal candidiasis (IAC) may include Candida involvement of peritoneum or intra-abdominal abscess and is burdened by high morbidity and mortality rates in surgical patients. Unfortunately, international guidelines do not specifically address this particular clinical setting due to heterogeneity of definitions and scant direct evidence. In order to cover this unmet clinical need, the Italian Society of Intensive Care and the International Society of Chemotherapy endorsed a project aimed at producing practice recommendations for the management of immune-competent adult patients with IAC. Methods A multidisciplinary expert panel of 22 members (surgeons, infectious disease and intensive care physicians) was convened and assisted by a methodologist between April 2012 and May 2013. Evidence supporting each statement was graded according to the European Society of Clinical Microbiology and Infection Diseases (ESCMID) grading system. Results Only a few of the numerous recommendations can be summarized in the Abstract. Direct microscopy examination for yeast detection from purulent and necrotic intra-abdominal specimens during surgery or by percutaneous aspiration is recommended in all patients with nonappendicular abdominal infections including secondary and tertiary peritonitis. Samples obtained from drainage tubes are not valuable except for evaluation of colonization. Prophylactic usage of fluconazole should be adopted in patients with recent abdominal surgery and recurrent gastrointestinal perforation or anastomotic leakage. Empirical antifungal treatment with echinocandins or lipid formulations of amphotericin B should be strongly considered in critically ill patients or those with previous exposure to azoles and suspected intra-abdominal infection with at least one specific risk factor for Candida infection. In patients with nonspecific risk factors, a positive mannan/antimannan or (1→3)-β- d -glucan (BDG) or polymerase chain reaction (PCR) test result should be present to start empirical therapy. Fluconazole can be adopted for the empirical and targeted therapy of non-critically ill patients without previous exposure to azoles unless they are known to be colonized with a Candida strain with reduced susceptibility to azoles. Treatment can be simplified by stepping down to an azole (fluconazole or voriconazole) after at least 5–7 days of treatment with echinocandins or lipid formulations of amphotericin B, if the species is susceptible a