1. Intra-Abdominal Candidiasis, Candida peritonitis
Paschalis Vergidis, MD, MSc
Infectious Diseases Consultant
Manchester University NHS Foundation Trust

2. Learning Objectives
To understand the different forms of intra-abdominal candidiasis
To discuss the risk factors for intra-abdominal candidiasis
To review the management and outcomes of intra-abdominal candidiasis

3. Spectrum of Disease
Kullberg BJ, Arendrup M. NEJM 2015; 373:

4. Intra-Abdominal Candidiasis
Common form of deep-seated candidiasis
Poorly studied compared to candidaemia
Accounts for ~10% of all cases of peritonitis
Bacterial co-infection is common
Co-infection in 2/3

5. Classification Vergidis et al. PLoS ONE. 2016; 11(4). e0153247
Primary peritonitis
No apparent breach of the GI tract
Secondary Peritonitis
Follows perforations, surgical leaks, trauma or other pathological process
Tertiary Peritonitis
Persistence or recurrence of intra-abdominal infection following treatment
Intra-Abdominal Abscess
Localized infection resulting from pathological process or breach of the GI tract
Infected Pancreatic Necrosis
Infection of the non-vitalized pancreatic tissue
Cholecystitis, cholangitis
Vergidis et al. PLoS ONE. 2016; 11(4). e

6. Risk factors Acquisition can be: Community-acquired Hospital-acquired
Recurrent GI surgery
GI tract perforations
GI anastomosis leakage
Prolonged broad-spectrum antibiotics
Acute renal failure
Total parenteral nutrition
ICU stay
Diabetes mellitus
Immunosuppression
Acquisition can be:
Community-acquired
Hospital-acquired
Healthcare-associated
Bassetti et al. Intensive Care Med. 2013; 39(12):

7. Microbiology Candida albicans (65-82%) C. glabrata <20%
C. tropicalis <10%
C. parapsilosis <5%
Other non-albicans Candida spp. ~2%
Mixed Candida spp. ~5%

8. Clinical manifestations
Fever
Abdominal pain (+/- guarding/rebound tenderness)
Nausea, vomiting
Purulent discharge from abdominal drains
Leucocytosis
Electrolyte abnormalities
Hypokalaemia, hypernatremia
Acidosis
Raised inflammatory markers
Clinical presentation is similar to bacterial peritonitis
Bacterial co-infection is common

9. Diagnosis Direct microscopy Non-culture based diagnostics
Intra-operative peritoneal or abscess fluid
Culture
Peritoneal or abscess fluid
Blood culture
In situ drains
Dialysis effluent
Non-culture based diagnostics
Serum β-D-Glucan
Candida PCR

10. Treatment Source control Prophylaxis Drainage of abscesses/collections
Repair of anatomical defects
Antifungals
Antifungal treatment has been shown to improve outcomes
Echinocandin
Fluconazole (if not critically ill)
Prophylaxis
Fluconazole in high-risk surgical patients
Dupont et al. Arch Surg (12):134-6
Montravers et al . Crit Care Med. 2006; 34 (3):
Vergidis et al. PLoS ONE. 2016; 11(4). e
Fluconazole: alternative that can be used in patients who are not critically ill, who have not been treated recently with fluconazole, and who are not considered likely to have a fluconazole-resistant isolate

11. Source control Drainage Percutaneous (CT-, ultrasound-guided)
Transgastric
Surgical procedures
Laparotomy to repair anatomical defects

12. Prognosis
Survival analysis by type of intra-abdominal candidiasis
Early source control and antifungal treatment are associated with improved outcomes
Mortality ~30% in recent studies
Mortality higher in patients admitted to the ICU
Vergidis et al. PLoS ONE. 2016;11(4): e

13. Predictors of mortality
Increased likelihood for survival:
Septic shock
High APACHE II* Score
Presence of abscess
Upper GI tract source
Antifungal therapy
Nosocomial peritonitis
Inadequate source control
*Acute Physiology and Chronic Health Evaluation II
Dupont et al. Arch Surg. 2002; 137 (12):134-6
Montravers et al . Crit Care Med. 2006; 34 (3):
Vergidis et al. PLoS ONE. 2016; 11(4). e

14. Summary
Intra-abdominal candidiasis is as common as Candida bloodstream infections
Mortality rates are comparable to that of candidaemia
Early source control and antifungal treatment are associated with improved outcomes

15. END