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The Role of Empiric Antifungal Therapy in Patients With Perforated Peptic Ulcer: An Updated Systematic Review and
Dimitrios Giannis1,2,3, Weiying Lu3, Salim El Hadwe4
1Department of Surgery, Flushing Hospital Medical Center, Queens, NY, USA.
Abstract:
Fungal growth is common in intraoperative cultures of patients with perforated peptic ulcer (PPU) leading to the common use of empiric antifungal therapy, with current evidence not clearly supporting this practice. The goal of this updated systematic review and meta-analysis was to synthesize the effect of empiric antifungals in patients with PPU. Eligible studies were identified through a comprehensive literature search in the MEDLINE (PubMed) and EMBASE databases, following the PRISMA 2020 statement. A total of eight studies were identified reporting on 1802 patients. The population consisted of 67.3% males (n = 121/1802), with a mean age of 59.1 ± 13.2 years. Most of the population underwent surgery (n = 1763/1802, 97.8%), which was most frequently omental patch (n = 1169/1411, 82.8%), while 12.8% (n = 140/1096) underwent laparoscopic repair. Intraoperative cultures were obtained in 73.7% (n = 1262/1713); blood cultures were obtained in 54.5% (n = 467/857) and were positive for fungus in 44.1% (n = 558/1262) and in 5.6% (n = 26/467), respectively. Empiric antifungal treatment was administered in 19.6% (n = 353/1802). The most common agent was fluconazole reported in 6 studies. At a mean follow-up of 34.4 ± 9.9 days, 191/1787 (10.7%) patients died. Patients with fungus-positive intraoperative cultures had significantly increased odds of having diabetes mellitus (OR: 1.55; 95% CI: 1.05-2.30), history of malignancy (OR: 2.80; 95% CI: 1.22-6.45), being on steroids (OR: 5.13; 95% CI: 1.37-19.3), and increased mortality (OR: 2.49; 95% CI: 1.67-3.70). Empiric antifungal therapy did not significantly decrease the odds for death (OR: 1.45; 95% CI: 0.33-6.41). The presence of fungi in the peritoneal fluid is associated with increased risk of death, that is not affected by administration of empiric antifungal therapy.
Insights
Empiric antifungal therapy for perforated peptic ulcer (PPU) patients with fungal growth in intraoperative cultures does not improve survival. Fungal presence increases mortality risk, but antifungals do not alter this outcome.
Area of Science:
- Medical research
- Clinical practice
- Infectious disease
Background:
- Fungal growth is frequently observed in intraoperative cultures of patients with perforated peptic ulcer (PPU).
- Empiric antifungal therapy is commonly administered in such cases, despite a lack of clear supporting evidence.
- This practice warrants re-evaluation through rigorous scientific synthesis.
Purpose of the Study:
- To systematically review and meta-analyze the effect of empiric antifungal therapy in patients with PPU.
- To determine if empiric antifungals impact mortality in PPU patients with positive intraoperative fungal cultures.
Main Methods:
- A systematic literature search was conducted in MEDLINE (PubMed) and EMBASE databases, adhering to PRISMA 2020 guidelines.
- Eight eligible studies involving 1802 patients with PPU were included in the meta-analysis.
- Data on patient demographics, surgical procedures, culture results, antifungal use, and outcomes were extracted and analyzed.
Main Results:
- Fungus-positive intraoperative cultures in PPU patients were associated with increased odds of diabetes mellitus, malignancy, steroid use, and mortality (OR: 2.49).
- Empiric antifungal therapy was administered to 19.6% of patients, with fluconazole being the most common agent.
- Empiric antifungal therapy did not significantly reduce the odds of death in these patients (OR: 1.45).
Conclusions:
- The presence of fungi in peritoneal fluid during PPU surgery is linked to a higher risk of mortality.
- Empiric antifungal administration does not appear to mitigate this increased mortality risk.
- Clinical guidelines for PPU management should reconsider the routine use of empiric antifungal therapy.
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