Antifungal prophylaxis for esophageal perforation: what’s the evidence?

Elsayed H, et al. The impact of systemic fungal infection in patients with perforated oesophagus. Ann R Coll Surg Engl. 2012 Nov;94(8):579-84.

“Some authors have concluded that antifungal prophylaxis could reduce mortality by 25% in non-neutropaenic critically ill patients and should be given prophylactically to patients at increased risk of invasive fungal infections.24 Patients with oesophageal perforation, the majority of whom are managed initially on critical care units, have several factors that increase their risk of secondary candidal infection including prolonged antibiotic use, surgery and being on total parental nutrition as well as a possible higher rate of candidal colonisation. As a result, this makes them ideal candidates for empirical antifungal therapy from diagnosis. This is the routine practice in our hospital now.

Until a randomised study comparing administration of antifungal versus no antifungal therapy proves empirically that there is no benefit of adding this medication, antifungal prophylaxis should be standard in patients with a ruptured oesophagus once diagnosed. We appreciate the limitation of this study in terms of the number of patients (27) but as a ruptured oesophagus is a rare presentation, it would be difficult to have a randomised study with a large number of patients.” (p. 583)

Hoffmann M, et al. Outcome and management of invasive candidiasis following oesophageal perforation. Mycoses. 2013 Mar;56(2):173-8.

Full-text for Emory users.

“Empirical antifungal treatment was evaluated in several clinical studies with inconsistent results. Recent guidelines recommended empirical therapy in high-risk non-neutropenic patients only with a B-III level of evidence.14 A possible explanation for the failure to detect a statistically significant difference in patients with and without empirical therapy, might be a selection bias for patients with a more severe disease, receiving empirical therapy. Patients with high APACHE-II scores are known to have an adverse outcome independent from antifungal therapy.15 We did not identify statistical differences between patients with or without candidemia. The involvement of different compartments of the human body (pleura, mediastinum, blood, urine) was also not associated with statistical significant differences.” (p. 177).

Jungbluth T, et al. [Complicated course of oesophageal perforations because of fungal infections]. Mycoses. 2005;48 Suppl 1:41-5. German. [Google translation].

“From our point of view, general antifungal therapy is not necessary in the case of an uncomplicated course of the disease of an esophageal perforation. In the case of esophageal perforation, however, microbiological monitoring should be ensured from the outset, especially with an intraoperative smear. Depending on the occurrence of septic course complications (pneumonia, mediastinitis, pleural empyema), the patient must react with systemic antifungal therapy in view of the general risk factors. Sufficient surgical rehabilitation and drainage of the compartments involved by the perforation, such as the pleura and mediastinum, are also of particular importance.” (p. 44).

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