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)

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Anti-fungal therapy in the treatment of perforated peptic ulcers: what’s the evidence?

Huston JM, et al. Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions. Surg Infect (Larchmt). 2019 Dec;20(8):593-600.

Full-text for Emory users.

Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. 

Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.

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