Candida infection in surgical patients

Abstract

Candida infections have become a common and serious problem in non‐neutropenic general surgical patients. This paper reviews the etiologic factors, pathogenesis of systemic candidiasis, and the more common syndromes of infection in surgical patients. Prophylactic and systemic therapy is detailed. The most significant factor inCandida infections is depression of host immune function. Significant abnormalities of T‐cells, monocytes, and neutrophils have been described in patients with systemicCandida infection and in patients shown to be at high risk of such infection (burned, malnourished, or septic patients). Systemic infection is a consequence of high density colonization at 1 or more sites. Topical therapy with nystatin, amphotericin B, or the imidazole derivatives is usually effective in terminating local colonization of skin lesions, the gastrointestinal tract, or the bladder. If local colonization is not controlled, the patient may progress to systemic infection. The primary diagnostic difficulty is determining when conversions to systemic infection has occurred. Serologic testing and blood culture techniques appear to be of value only late in the course of infection. For this reason, the assessment of culture results from multiple sites appears to be of value. Treatment is begun with systemic amphotericin if the patient is immunodepressed or has ≥ 3 sites positive forCandida. In nonneutropenic patients, relatively short therapy appears effective. Treatment of endocarditis requires several (4–6) weeks of therapy, and current evidence suggests that early surgery with valve replacement may improve survival.

Proposed definitions for diagnosis, severity scoring, stratification, and outcome for trials on intraabdominal infection

“…Cultures from the operative site or blood stream often grow organisms of unclear significance which is parallelled by the experience that changing the antibiotic regimen is insignificant unless directed against organism-proven septicemia. Bacteriological studies have shown that mortality in these patients was significantly related to findings of enterococci [44--46], Staphylococcus epidermidis [47][48][49], or Candida [50][51][52]. Systematic analysis of the bacteriology of patients with intraabdominal infection and multiple systems organ failure has clearly demonstrated that the important flora is different from that of secondary peritonitis [53,54].…”

Indications for Therapy for Fungemia in Postoperative Patients

“…The histologie findings have been previously described. 10 The classic syndrome of disseminated candidiasis was therefore identified in 33% (7/21) of patients who died after an episode of fungemia that had not been adequately treated. In two of these patients, Candida myocardial emboli were considered the direct cause of death.…”