What are the risks of developing a peritoneal fungal infection post-operatively?

From the Guidelines

Peritoneal fungal infections after surgery should be treated with empirical antifungal therapy, specifically an echinocandin such as caspofungin, micafungin, or anidulafungin, in patients with septic shock or post-operative infections where the presence of yeast is associated with a poor prognosis, as recommended by the WSES 2016 consensus conference 1. The management of peritoneal fungal infections after surgery is crucial to prevent poor outcomes, including increased mortality, as demonstrated by Montravers et al. 1. The epidemiological role of Candida spp. in intra-abdominal infections (IAIs) has not been conclusively defined, but isolation of Candida spp. in samples from IAIs is associated with poor outcomes 1.

Key Considerations

• The presence of yeast in the peritoneal fluid of post-operative peritonitis is an independent risk factor for death in patients with septic shock, as shown by Riché et al. 1.
• Empirical antifungal therapy is justified in two situations: patients with septic shock in community-acquired infections or patients with post-operative infections, as stated by the WSES 2016 consensus conference 1.
• The optimal duration of definitive treatment is not established, but experts recommend a duration of around 2 to 3 weeks, based on the high rates of recurrence and relapse in candida IAIs 1.

Treatment Recommendations

• Echinocandins, such as caspofungin, micafungin, or anidulafungin, are recommended as empirical antifungal therapy in critically ill patients with CA-IAIs or HAI-IAIs 1.
• Fluconazole may be used as first-line therapy in other cases, but its use is limited by the presence of Candida glabrata, which is resistant to azole agents 1.
• De-escalation of empirical antifungal therapy is a safe procedure, as illustrated by recent studies, and may be associated with decreased SAT consumption 1.

Additional Measures

• Surgical intervention may be necessary to drain abscesses or remove infected material.
• Peritoneal lavage with antifungal solutions may be performed in severe cases.
• Early diagnosis through peritoneal fluid cultures and prompt initiation of appropriate antifungal therapy are crucial for improving outcomes and preventing complications such as abscess formation, sepsis, and multiorgan failure.

From the Research

Peritoneal Fungal Infection after Surgery

• Peritoneal fungal infection has become more common in recent years, with Candida being the most common cause 2.
• Candida peritonitis is considered a severe disease and is regarded as an independent risk factor for mortality in postoperative peritonitis 2.
• Factors associated with fungal infection include old age, high lag period, peritoneal contamination, length of hospital stay, presence of co-morbidities, shock at presentation, and postoperative complications 2.

Treatment of Peritoneal Fungal Infection

• Early antifungal therapy (within 72 hours after surgery) can reduce morbidity due to Candida peritonitis, but may not affect mortality 2.
• Oral fluconazole can be safely used as initial therapy in patients with fungal peritonitis complicating continuous ambulatory peritoneal dialysis (CAPD) 3.
• Combination of intravenous amphotericin B and oral flucytosine with deferred catheter replacement may be associated with a relatively low incidence of peritoneal dialysis technique failure, without affecting mortality 4.
• Catheter removal is often necessary for successful treatment of fungal peritonitis, as antifungal therapy alone may not be sufficient to eradicate the infection 5.

Complications of Peritoneal Fungal Infection

• Fungal peritonitis is associated with significant mortality and high risk of peritoneal failure 4.
• Antifungal lock therapy may not be effective in treating fungal peritonitis and can lead to detrimental complications 6.
• Disease-related mortality can be as high as 14.3% in patients with fungal peritonitis complicating CAPD 3.