Fungal infections in severe acute pancreatitis

Abstract

Severe acute pancreatitis (SAP) is associated with significant morbidity and mortality. The majority of deaths related to SAP are the result of infectious complications. Although bacterial infections are most commonly encountered, fungal infections are increasingly being recognized. Candida is the most common fungal infection. The occurrence of fungal infection in patients with acute pancreatitis adversely affects the clinical course, leading to a higher incidence of systemic complications, and possibly mortality as well. Important risk factors for fungal infection in patients with acute pancreatitis include broad-spectrum antibiotics, prolonged hospitalization and surgical/endoscopic interventions, use of total parenteral nutrition, and mechanical ventilation. Patients with higher severity of pancreatitis are at a greater risk. The pathogenesis of fungal infection in patients with acute pancreatitis is multifactorial. Translocation of microorganisms across the gut epithelium, lymphocyte dysfunction, and the virulence of the invading microorganisms play important roles. Histological demonstration of fungi remains the gold standard of diagnosis, but a positive biopsy is rarely obtained. The role of biomarkers in the diagnosis is being investigated. As early diagnosis and treatment can lead to improved outcome, a high index of suspicion is required for prompt diagnosis. Limiting the use of broad-spectrum antibiotics, early introduction of enteral nutrition, and timely change of vascular catheters are important preventive strategies. The role of antifungal prophylaxis remains controversial. Surgical necrosectomy with antifungal therapy is the most widely used treatment approach. Clinical trials on antifungal prophylaxis are needed, and indications for surgical intervention need to be clearly defined.

Infections and Use of Antibiotics in Patients Admitted for Severe Acute Pancreatitis: Data from the EPIC II Study

“…Fungal infections are equally feared in this setting, yet fungi were less predominant in this series compared to previous reports [14,15]. The frequent use of anti-fungal agents in our study may explain these findings.…”

Antibiosis of Necrotizing Pancreatitis

“…The usage of antifungal prophylaxis has been debated without any clear tendencies for the last 15 years [ 58 , 59 , 60 , 61 , 62 , 63 ]. The fact that fungal infection, most often caused by Candida species, is a predictor for a worse outcome in necrotizing pancreatitis is widely established [ 59 , 60 , 63 ]. Especially antibiotic treatment promotes the overgrowth of unaffected microorganism and is thought to be a major risk factor for fungal infection [ 59 , 60 , 64 ].…”

“…The fact that fungal infection, most often caused by Candida species, is a predictor for a worse outcome in necrotizing pancreatitis is widely established [ 59 , 60 , 63 ]. Especially antibiotic treatment promotes the overgrowth of unaffected microorganism and is thought to be a major risk factor for fungal infection [ 59 , 60 , 64 ]. Thus, there is an ongoing debate whether an antifungal prophylaxis should be generally combined with prophylactic antibiotics [ 14 , 58 , 59 , 60 , 62 ].…”

Antibiotics in severe acute pancreatitis

“…Treatment should not be continued beyond that time without evidence of infection provided by bacterial growth on culture. When such evidence exists, appropriate antibiotic therapy should be guided by the results of sensitivity testing in accordance with critical care medicine guidelines [36]. Limited use of broad-spectrum antibiotics, early introduction of enteral nutrition, and timely change of vascular catheters are important preventive strategies.…”

“…It is accepted to initiate it after surgical necrosectomy, even without a microbiological diagnosis [36].…”