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Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer
Galinos Barmparas1, Adel Alhaj Saleh2, Raymond Huang1
1Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Introduction:
Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI).
Methods:
This was a secondary analysis of a multicenter, case-control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts.
Results:
A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53).
Conclusion:
For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary.
Study Type:
Original article, case series.
Level Of Evidence:
III.
Insights
Empiric antifungals (AF) are often used for perforated peptic ulcers (PPU), but this study found no benefit in preventing organ space infections (OSI). The use of empiric AF in PPU patients is unnecessary and should be reconsidered.
Area of Science:
- Surgical infection control
- Gastrointestinal surgery outcomes
- Antifungal stewardship
Background:
- Perforated peptic ulcer (PPU) management often includes empiric antifungals (AF).
- Variability exists in AF use across institutions.
- The association between empiric AF and organ space infection (OSI) in PPU is unclear.
Purpose of the Study:
- To investigate the variation in empiric AF use for PPU.
- To determine if empiric AF prevents OSI in PPU patients.
- To assess the impact of empiric AF on Candida-related OSI.
Main Methods:
- Secondary analysis of a multicenter case-control study (2011-2018).
- Compared patients who received empiric AF within 24 hours of surgery versus those who did not.
- Assessed OSI and Candida spp. OSI as primary and secondary outcomes, respectively.
- Used logistic regression for adjusted analysis.
Main Results:
- 43% of 554 PPU patients received empiric AF, with significant center variation (25%-68%).
- Empiric AF use was not associated with a reduced incidence of OSI (aOR 1.04; p=0.86).
- No significant difference in Candida-related OSI between groups (aOR 1.29; p=0.53).
Conclusions:
- Empiric antifungals offer no significant clinical benefit in preventing OSI in PPU patients.
- The use of empiric AF in this context is not supported by the evidence.
- Antifungal stewardship should be considered for PPU management.
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