From the Guidelines
Esophageal candidiasis risk after surgery can be mitigated with fluconazole 200-400mg daily during the perioperative period, particularly for high-risk patients, as recommended by recent guidelines 1. The risk of esophageal candidiasis is increased after certain surgeries, especially those involving the gastrointestinal tract or procedures requiring prolonged intubation. Patients who are immunocompromised, malnourished, or on broad-spectrum antibiotics are at highest risk. Some key factors that contribute to this risk include:
- Recent antibiotics
- Local or systemic steroids or immunosuppression
- Malignancy
- Proton pump inhibitor use
- Older age
- Chronic alcohol use
- Chronic kidney disease
- Diabetes
- Motility disorders that lead to esophageal stasis 1 Treatment for established infection consists of fluconazole 200mg on day one followed by 100mg daily for 14-21 days, as supported by the most recent guidelines 1. Alternative options include itraconazole oral solution 200mg daily or voriconazole 200mg twice daily if fluconazole resistance is suspected. Severe cases may require intravenous echinocandins like caspofungin (70mg loading dose, then 50mg daily). Risk reduction strategies include:
- Optimizing nutritional status before surgery
- Minimizing unnecessary antibiotic use
- Controlling blood glucose levels
- Prompt removal of central lines when no longer needed Candida infections develop when normal flora balance is disrupted by antibiotics or when immune defenses are compromised by surgical stress, allowing opportunistic overgrowth of yeast organisms in the esophageal mucosa 1.
From the FDA Drug Label
The efficacy of oral voriconazole 200 mg twice daily compared to oral fluconazole 200 mg once daily in the primary treatment of EC was demonstrated in Study 150-305, a double-blind, double-dummy study in immunocompromised patients with endoscopically-proven EC.
Table 16: Success Rates in Patients Treated for Esophageal Candidiasis Population Voriconazole FluconazoleDifference % (95% CI) PP b 113/115 (98.2%) 134/141 (95.0%) 3.2 (-1.1,7.5) ITT c 175/200 (87.5%) 171/191 (89.5%) -2.0 (-8.3,4. 3)
The risk of esophageal candidiasis after surgery is not directly addressed in the provided drug label. However, the label does discuss the efficacy of voriconazole in treating esophageal candidiasis in immunocompromised patients.
- Key points:
- Voriconazole showed comparable efficacy to fluconazole in treating esophageal candidiasis.
- The success rates for voriconazole and fluconazole were 87.5% and 89.5%, respectively, in the Intent-to-Treat population.
- The label does not provide information on the risk of esophageal candidiasis after surgery. 2
From the Research
Esophageal Candidiasis Risk After Surgery
- Esophageal candidiasis is an opportunistic infection that can occur in patients with compromised immune systems, including those undergoing surgery 3, 4.
- Patients with esophageal disease, particularly those with carcinoma or undergoing neoadjuvant chemoradiation therapy, are at higher risk of Candida colonization 5.
- Esophageal surgery may increase the risk of systemic Candida infection in critical patients requiring postoperative ICU admission 5.
- The diagnosis of esophageal candidiasis is typically made by endoscopic examination, which can directly observe white mucosal plaque-like lesions and exudates adherent to the mucosa 3, 4.
- Treatment of esophageal candidiasis usually involves systemic antifungal drugs, such as fluconazole or itraconazole, given orally in a defined course 3, 6, 7.
Risk Factors for Esophageal Candidiasis After Surgery
- Immunocompromised patients, including those with HIV/AIDS, leukemia, diabetes, or those receiving corticosteroids, radiation, or chemotherapy, are at higher risk of developing esophageal candidiasis 3, 4.
- Patients with esophageal motility disorders, such as cardiac achalasia or scleroderma, are also at increased risk 3.
- The use of antibiotics and other medications that suppress the immune system can also increase the risk of esophageal candidiasis 5, 4.
Prevention and Management of Esophageal Candidiasis After Surgery
- Pharmacological attempts to prevent or reduce the magnitude of Candida colonization may be worthwhile before surgery 5.
- Antifungal oral prophylaxis with nonabsorbable drugs may lower the incidence of candidemia in patients with gastrointestinal Candida colonization, especially in those candidates for postoperative ICU admission 5.
- Treatment of esophageal candidiasis should be determined by the clinical and immune status of the patient, and may involve the use of systemic antifungal drugs, such as fluconazole or itraconazole 3, 6, 7.