Background: Intra-abdominal candidiasis (IAC) is an important type of invasive candidiasis that is as common as candidemia. Surgical intervention is recognized as a key component of successful management. The benefit of antifungal therapy in IAC is not established.
Methods: We performed a retrospective study of adult patients with microbiological evidence of IAC diagnosed at the University of Pittsburgh Medical Center in 2012-2013.
Results: 163 patients had IAC. 25% were immunocompromised, including 12% with solid organ transplant (SOT). IAC was preceded by abdominal surgery in 53%. 63% (n=103) had gastrointestinal (GI) luminal disease, most commonly involving the colon (followed by small bowel, stomach and duodenum). Types of IAC were primary peritonitis (5%, all associated with cirrhosis), secondary peritonitis (32%), intra-abdominal abscesses (55%), cholangitis (3%) and infected pancreatic necrosis (5%). At disease onset, 18% had septic shock, which was more common in patients with peritonitis than abscess (p=0.06).
C. albicans was most common (57%), followed by C. glabrata (24%), C. parapsilosis (10%), and other Candida species. Infection with two Candida species occurred in 10%, and bacterial co-infection in 68%. C. glabrata was more likely than C. albicans to cause IAC in patients with ≥2 prior abdominal surgeries (53% vs 22%, p=0.02), and to be involved in co-infections with multiple-drug resistant Gram-negative bacteria (14% vs 2%; p=0.005).
All patients underwent drainage procedures. Only 72% received antifungal treatment within 5 days of IAC. The 100-day mortality rate was 28%. Primary peritonitis was associated with the highest mortality (89%), followed by secondary peritonitis (40%) and abscesses (17%). Increased age (p=0.001) and SOT (p=0.05) were independent risk factors for death, while abscess was protective (p=0.001) by multivariate analysis. Among patients with GI luminal disease, intra-abdominal abscess (p=0.01) and antifungal therapy within 5 days (p=0.02) were protective against death.
Conclusion: IAC is associated with high mortality. We showed for the first time that early administration of an antifungal agent in conjunction with drainage and/or surgical intervention improved outcomes, especially among patients with GI luminal disease.
M. H. Nguyen, None
R. K. Shields, Merck: Investigator , Research grant
Astellas: Investigator , Research grant
S. Y. Park, None
C. Clancy, None