Intra-abdominal candidiasis: it’s still a long way to get unquestionable data

Abstract

Intra-abdominal candidiasis (IAC) appears as the second most frequent cause of invasive fungal infection in the intensive-care unit (ICU) [1]. In the AmarCand 1 study, a prospective, multicenter, French observational study, IAC was observed in 34 % of ICU patients with proven invasive candidiasis [1]. Intra-abdominal candidiasis accounts for more than 10 % of all cases of peritonitis and is associated with mortality rates between 25 and 60 % [2,3].Intra-abdominal candidiasis shares many similarities with candidaemia, including conventional risk factors [4] and high morbidity and mortality rates [2,3,5]. While the need for early and adequate antifungal treatment of candidaemia has been clearly demonstrated, no clinical study has ever assessed the need to treat IAC, raising the question of the real pathogenicity of these organisms.Based on the demonstration that delayed antifungal treatment in candidaemia is a factor of poor prognosis, empirical broad-spectrum antifungal treatment is routinely prescribed in IAC. Interestingly, American and European guidelines do not address this issue while the IDSA guidelines for intra-abdominal infections give only weak therapeutic recommendations [6].Recently, a consensus of multinational experts proposed enhanced recommendations for the management of IAC [7]. Using these criteria, Bassetti et al., in an article recently published in Intensive Care Medicine, reported a retrospective international cohort of 481 patients treated for IAC [8]. The authors should be congratulated for the largest cohort of IAC ever published and for the interesting data presented here. Their results deserve some comments to emphasize the complexity for organizing studies on this topic.Despite their attempt to obtain a homogeneous cohort, there is room for improvement in future trials. Their study population gathered together different clinical situations (secondary and tertiary peritonitis, abdominal abscesses, pancreatitis, etc.) in patients with very different underlying diseases and medical history (hospitalized in ICU and surgical wards but also in medical wards, hematology, oncology, etc.) with different levels of severity (with or without septic shock) related to community-acquired, health care-associated and hospital-acquired infections. Overall, a 49.5 % mortality rate was observed in ICU patients compared to 22.8 % in non-ICU patients. Not surprisingly, septic shock and high APACHE II score appeared as independent predictors of mortality, all the more so in patients with these life-threatening conditions who were not all admitted in ICU.A second important issue in the manuscript of Bassetti et al. is the strong correlation between inadequate source control and increased mortality [8]. These findings confirm what some of the authors have recently published [9]. Interestingly, the issue of source control is a matter of

Intra-Abdominal Candidiasis: The Importance of Early Source Control and Antifungal Treatment

“…Epidemiologic reports, antifungal treatment trials and diagnostic studies of invasive candidiasis have focused largely on candidemia [ 4 ]. Research on IAC is limited by the disease’s clinical heterogeneity, a lack of standardized disease definitions, and difficulties in establishing diagnoses [ 3 , 5 , 6 ].…”

“…IAC encompasses a range of disease manifestations, which occur in patients with various underlying conditions and risk factors involving the gastrointestinal (GI) tract and digestive system [ 6 , 7 ]. The clinical significance of Candida in cultures of samples from intra-abdominal sites is controversial, as mixed infections with bacteria are frequent and the settings in which antifungal treatment is beneficial are not established conclusively [ 6 , 8 ]. Clearly, Candida contributes to poor outcomes in some patients with intra-abdominal infections [ 7 , 9 ].…”

Diagnosis and treatment of invasive Candida infections – a review article

“…in cultures of samples from intra-abdominal sites is controversial and blood cultures are often negative. There are limited data on the utility of using surrogate markers (42,43). Because of diagnostic dificulties, empiric antifungal therapy should be considered for patients with clinical evidence of intraabdominal infection and signiicant risk factors for candidiasis, including recent abdominal surgery, anastomotic leaks, or necrotizing pancreatitis (49).…”

Appropriate Source Control and Antifungal Therapy are Associated with Improved Survival in Critically Ill Surgical Patients with Intra‐abdominal Candidiasis

“…According to the epidemiological data over the last decades, the mortality rate of patients with IAC was about 25-40%; for those combined with septic shock, the mortality rate was up to 60% [4][5][6]. Unfortunately, IAC remains poorly understood when compared with candidemia [7][8][9]. Previous studies showed that, for patients with candidemia, early antifungal therapy and timely source control improve survival [10][11][12][13].…”