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Pre-Operative Anti-Fungal Therapy Does Not Improve Outcomes in Perforated Peptic Ulcers
Christopher B Horn1, Adrian A Coleoglou Centeno1, Rohit K Rasane1
11 Department of Surgery, Washington University in St Louis , St. Louis, Missouri.
Background:
With the advent of anti-Helicobacter pylori therapy, hospital admissions for peptic ulcer disease (PUD) have declined significantly since the 1990s. Despite this, operative treatment of PUD still is common. Although previous papers suggest that Candida in peritoneal fluid cultures may be associated with worse outcomes in patients with perforated peptic ulcers (PPUs), post-operative anti-fungal therapy has not been effective. We hypothesized that pre-operative anti-fungal drugs improve outcomes in patients with PPUs undergoing operative management.
Patients And Methods:
A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with PPUs. Demographics and clinical outcomes were abstracted. Pre-operative anti-fungal use, intra-operative peritoneal fluid cultures, and infectious outcomes were abstracted manually. We compared outcomes and the presence of fungal infections in patients receiving peri-operative anti-fungal drugs in the entire cohort and in patients with intra-operative peritoneal fluid cultures. Frequencies were compared by the Fisher exact or χ2 test as appropriate. The Student's t-test was used for continuous variables.
Results:
There were 107 patients with PPUs who received operative management; 27 (25.2%) received pre-operative anti-fungal therapy; 33 (30.8%) received peritoneal fluid culture, and 17 cultures (51.5%) were positive for fungus. The presence of fungus in the cultures did not affect the outcomes. There were no differences in length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, 30-day re-admission rates, or rates of intra-abdominal abscess formation or fungemia in patients who received pre-operative anti-fungal drugs regardless of the presence of fungi in the peritoneal fluid.
Conclusion:
Candida has been recovered in 29%-57% of peritoneal fluid cultures in patients with PPUs. However, no studies have evaluated pre-operative anti-fungal therapy in PPUs. Our data suggest that pre-operative anti-fungal drugs are unnecessary in patients undergoing operative management for PPU.
Insights
Pre-operative antifungal drugs did not improve outcomes for patients with perforated peptic ulcers (PPUs). Fungal presence in cultures did not impact patient recovery, suggesting these drugs are unnecessary for PPU operative management.
Area of Science:
- Surgical outcomes research
- Infectious disease management
- Gastroenterology
Background:
- Peptic ulcer disease (PUD) admissions have decreased due to anti-Helicobacter pylori therapy.
- Operative treatment for PUD remains common.
- Previous studies suggest Candida in peritoneal fluid may worsen outcomes in perforated peptic ulcers (PPUs), but post-operative antifungals were ineffective.
Purpose of the Study:
- To investigate if pre-operative antifungal drugs improve outcomes in patients with PPUs undergoing surgery.
- To determine the impact of fungal presence in peritoneal fluid on patient outcomes.
Main Methods:
- A prospectively maintained Acute and Critical Care Surgery database (2008-2015) was queried for patients with PPUs.
- Data on demographics, clinical outcomes, pre-operative antifungal use, and peritoneal fluid cultures were abstracted.
- Outcomes were compared between patients receiving peri-operative antifungals and those with positive fungal cultures.
Main Results:
- Of 107 patients with PPUs, 27 received pre-operative antifungals, and 33 had peritoneal fluid cultures (17 positive for fungus).
- Fungal presence in cultures did not significantly affect outcomes.
- No differences were observed in length of stay, ICU stay, ventilator days, readmission rates, or infectious complications between groups.
Conclusions:
- Candida is frequently found in peritoneal fluid cultures of PPU patients (29%-57%).
- This study is the first to evaluate pre-operative antifungal therapy in PPUs.
- Pre-operative antifungal drugs appear unnecessary for patients undergoing operative management for PPU.
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