Are antifungals necessary for perforated intestines?

From the Guidelines

Antifungals are not necessary for most patients with perforated intestines, as the evidence suggests that antifungal therapy does not improve outcomes in non-critically ill or non-immunocompromised patients presenting with gastrointestinal perforation 1.

Key Points

• The routine empiric use of antifungal therapy in non-critically ill or non-immunocompromised patients presenting with gastrointestinal perforation should not be routinely recommended 1.
• Antifungal therapy may be reserved for patients who are critically ill and/or severely immunocompromised, as they are at higher risk for invasive candidiasis 1.
• Fluconazole or echinocandin antifungals may be used as first-line therapy for invasive infections, and candidemia in non-neutropenic critically ill patients 1.
• The presence of fungi in intra-abdominal infections may not independently indicate the need for longer course of antimicrobial therapy 1.

Specific Considerations

• Patients with recent abdominal surgery, intra-abdominal events, or those with recurrent gastroduodenal perforation, anastomotic leaks, or acute necrotizing pancreatitis are at higher risk for invasive candidiasis and may benefit from empiric antifungal therapy 1.
• The choice of antifungal agent should be guided by the Candida species isolated and knowledge of the local epidemiology, including antifungal susceptibility patterns 1.
• Source control with adequate drainage and/or debridement is an important part of therapy for intra-abdominal candidiasis 1.

From the Research

Antifungal Therapy for Perforated Intestines

• The use of antifungal therapy for perforated intestines is a topic of debate, with some studies suggesting that it may not be necessary for all patients 2, 3, 4.
• A study published in 2017 found that antifungal therapy did not improve outcomes, including 30-day all-cause mortality, in patients with community-acquired perforated peptic ulcer-associated peritonitis with Candida species isolated from their peritoneal fluid 2.
• Another study published in 2019 reviewed the evidence on the role of empiric anti-fungal therapy in the treatment of perforated peptic ulcer disease and found that the current evidence does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU 3.
• A 2022 study found that receipt of antifungal therapy was not associated with improved clinical outcomes in critically ill patients with perforated peptic ulcer 4.
• A literature review published in 2023 found that antifungal prophylaxis is appropriate in patients who meet the criteria for high-risk invasive candidiasis, but the evidence for using antifungal therapy empirically for all surgical procedures is lacking 5.
• A 2024 study found that the use of antifungals for patients with perforated peptic ulcer disease was variable, and that receiving antifungals was associated with higher morbidity in the non-immunocompromised cohort 6.

Patient-Specific Factors

• Patient-specific factors, such as the presence of pre-operative shock and acidosis, and the level of abundance of fungal growth on intra-operative samples, may influence the decision to prescribe antifungal therapy 6.
• Immunocompromised patients may benefit from antifungal therapy, but the evidence is not clear-cut 2, 5.
• The American Society of Anesthesiologists (ASA) score may also be a factor in determining the need for antifungal therapy, with patients having an ASA score of 3 or more being more likely to receive antifungals 6.

Clinical Outcomes

• The clinical outcomes of patients with perforated intestines who receive antifungal therapy are not consistently improved compared to those who do not receive antifungal therapy 2, 3, 4.
• In some cases, receiving antifungals may be associated with higher morbidity, particularly in the non-immunocompromised cohort 6.
• Further studies are needed to determine the specific subpopulations of patients who may benefit from antifungal therapy and to define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost 3, 5.