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A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts

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Abstract

Introduction

intra-abdominal candidiasis (IAC) may include Candida involvement of peritoneum or intra-abdominal abscess and is burdened by high morbidity and mortality rates in surgical patients. Unfortunately, international guidelines do not specifically address this particular clinical setting due to heterogeneity of definitions and scant direct evidence. In order to cover this unmet clinical need, the Italian Society of Intensive Care and the International Society of Chemotherapy endorsed a project aimed at producing practice recommendations for the management of immune-competent adult patients with IAC.

Methods

A multidisciplinary expert panel of 22 members (surgeons, infectious disease and intensive care physicians) was convened and assisted by a methodologist between April 2012 and May 2013. Evidence supporting each statement was graded according to the European Society of Clinical Microbiology and Infection Diseases (ESCMID) grading system.

Results

Only a few of the numerous recommendations can be summarized in the Abstract. Direct microscopy examination for yeast detection from purulent and necrotic intra-abdominal specimens during surgery or by percutaneous aspiration is recommended in all patients with nonappendicular abdominal infections including secondary and tertiary peritonitis. Samples obtained from drainage tubes are not valuable except for evaluation of colonization. Prophylactic usage of fluconazole should be adopted in patients with recent abdominal surgery and recurrent gastrointestinal perforation or anastomotic leakage. Empirical antifungal treatment with echinocandins or lipid formulations of amphotericin B should be strongly considered in critically ill patients or those with previous exposure to azoles and suspected intra-abdominal infection with at least one specific risk factor for Candida infection. In patients with nonspecific risk factors, a positive mannan/antimannan or (1→3)-β-d-glucan (BDG) or polymerase chain reaction (PCR) test result should be present to start empirical therapy. Fluconazole can be adopted for the empirical and targeted therapy of non-critically ill patients without previous exposure to azoles unless they are known to be colonized with a Candida strain with reduced susceptibility to azoles. Treatment can be simplified by stepping down to an azole (fluconazole or voriconazole) after at least 5–7 days of treatment with echinocandins or lipid formulations of amphotericin B, if the species is susceptible and the patient has clinically improved.

Conclusions

Specific recommendations were elaborated on IAC management based on the best direct and indirect evidence and on the expertise of a multinational panel.

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Abbreviations

SITI:

Italian Society of Intensive Care

ISC:

International Society of Chemotherapy

ESCMID:

European Society of Clinical Microbiology and Infectious Diseases

EP:

Expert panel

GI:

Gastrointestinal

IAC:

intra-abdominal candidiasis

ICU:

Intensive care unit

CLSI:

Clinical and Laboratory Standards Institute

EUCAST:

European Committee on Antimicrobial Susceptibility Testing

CAGTA:

C. albicans germ tube antibodies

BDG:

(1→3)-β-d-Glucan

IDSA:

Infectious Diseases Society of America

CNS:

Central nervous system

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Conflicts of interest

M.B. serves on scientific advisory boards for Pfizer Inc., Merck Serono, and Astellas Pharma Inc. and has received funding for travel or speaker honoraria from Pfizer Inc., Merck Serono, Gilead Sciences, Teva Inc., and Astellas Pharma Inc. C.T. has been paid for lectures and advisory boards for Pfizer, Novartis, Merck, Astellas, Gilead, Angelini, and Zambon Group. F.G.D.R., F.C., G.S., A.C., and M.T. have been speakers or consultants for Gilead Sciences, MSD, and Pfizer. T.J.W. has received research grants from Astellas, Novartis, Merck, ContraFect, and Pfizer and has been speaker or consultant for Astellas, ContraFect, Drais, iCo, Novartis, Pfizer, Methylgene, SigmaTau, and Trius. C.E. has served on advisory boards and received speaker honoraria from Pfizer Inc., Astellas Pharma Inc., and MSD. G.P. has received research grants from Gilead, Pfizer, Astellas, and MSD, has acted as paid consultant to Astellas, Gilead, and MSD, and is a member of the Astellas and MSD speaker’s bureaus. C.V. received grants as speaker/moderator in meetings sponsored by Pfizer, Gilead, MSD, Astellas, Abbott, Nadirex International, and BMS and received grants for participation in advisory boards by Gilead, Astellas, MSD, and Pfizer. Further, he obtained research grants for his institution from Pfizer, MSD, Gilead, Abbott, Jansen, BMS, and Novartis. D.H.K. serves as a consultant to and on scientific advisory boards for Pfizer Inc. and has received funding for travel or speaker honoraria from Pfizer Inc. The other authors serve on scientific advisory board of MSD. O.L. serves on scientific advisory boards for MSD and Astellas Pharma Inc. and has received speaker honoraria from Sanofi Aventis, Pfizer Inc., MSD, and Astellas Pharma Inc.

Author information

Authors and Affiliations

  1. Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy

    Matteo Bassetti & Elda Righi

  2. Hematology Unit, Oncology Department, Hospital C. Massaia, Asti, Italy

    Monia Marchetti

  3. Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

    Arunaloke Chakrabarti

  4. Department of General Surgery, Fatebenefratelli-Isola Tiberina, Rome, Italy

    Sergio Colizza

  5. Critical Care and Emergency Clinical Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain

    Jose Garnacho-Montero

  6. The Miller School of Medicine at the University of Miami, Jackson Memorial Hospital, Miami, USA

    Daniel H. Kett

  7. Servicio de Microbiología-Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Patricia Munoz

  8. Clinica Malattie Infettive, Dipartimento Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy

    Francesco Cristini & Pierluigi Viale

  9. Third Department Pediatrics, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Anastasia Andoniadou & Emmanuel Roilides

  10. Clinica di Anestesia e Rianimazione, University of Udine, Udine, Italy

    Giorgio Della Rocca

  11. Division of General Surgery and Organ Transplantation, Department of Surgery, Catholic University of Rome, Rome, Italy

    Gabriele Sganga

  12. Medical Mycology Research Laboratory, Weill Cornell Medical Center and Cornell University, New York, USA

    Thomas J. Walsh

  13. U.O.C. Malattie Infettive, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy

    Carlo Tascini & Francesco Menichetti

  14. Institute of Infectious Diseases, Università Cattolica del Sacro Cuore, Rome, Italy

    Mario Tumbarello

  15. Department of General, Visceral and Thoracic Surgery, Klinikum Peine Academic Hospital of Medical University Hannover, Hannover, Germany

    Christian Eckmann

  16. Infectious Disease Clinic, San Martino Hospital, University of Genoa, Genoa, Italy

    Claudio Viscoli

  17. Pulmonary and Critical Care Medicine Division, Washington Hospital Center, Washington, DC, USA

    Andrew F. Shorr

  18. Service de Réanimation et Maladies Infectieuses, Centre Hospitalier Chatiliez, Tourcoing, France

    Olivier Leroy

  19. Fourth Department of Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

    George Petrikos

  20. Department of Medical Sciences, Infectious Diseases Clinic at Amedeo di Savoia Hospital, University of Turin, Turin, Italy

    Francesco Giuseppe De Rosa

  21. Infectious Disease Division, Azienda Ospedaliera Universitaria Santa Maria della Misericordia, Piazzale Santa Maria della Misericordia 15, 33100, Udine, Italy

    Matteo Bassetti

Authors
  1. Matteo Bassetti
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  2. Monia Marchetti
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  3. Arunaloke Chakrabarti
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  4. Sergio Colizza
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  5. Jose Garnacho-Montero
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  6. Daniel H. Kett
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  7. Patricia Munoz
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  8. Francesco Cristini
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  9. Anastasia Andoniadou
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  10. Pierluigi Viale
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  11. Giorgio Della Rocca
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  12. Emmanuel Roilides
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  13. Gabriele Sganga
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  14. Thomas J. Walsh
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  15. Carlo Tascini
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  16. Mario Tumbarello
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  17. Francesco Menichetti
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  18. Elda Righi
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  19. Christian Eckmann
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  20. Claudio Viscoli
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  21. Andrew F. Shorr
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  22. Olivier Leroy
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  23. George Petrikos
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  24. Francesco Giuseppe De Rosa
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Corresponding author

Correspondence to Matteo Bassetti.

Additional information

Take-home message: A group of clinical experts endorsed by the Italian Society of Intensive Care and the International Society of Chemotherapy elaborated specific statements and practice recommendations addressing the management of intra-abdominal invasive candidiasis based on the best direct and indirect evidence. International guidelines do not specifically address this particular clinical setting and scant direct evidence is available.

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Bassetti, M., Marchetti, M., Chakrabarti, A. et al. A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts. Intensive Care Med 39, 2092–2106 (2013). https://doi.org/10.1007/s00134-013-3109-3

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  • DOI: https://doi.org/10.1007/s00134-013-3109-3

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