Candida peritonitis.

BACKGROUND: Fungal infections including Candida peritonitis (CP) are being observed with increasing frequency in the ICU. We summarize current knowledge on epidemiology, risk factors, diagnostic tests and treatment options in the previously immunocompetent patient suffering from CP.

METHODS: An electronic medical database search using "Candida" and "Peritonitis" as main search terms in conjunction with specific key words relevant to the topic.

RESULTS: CP is associated with high mortality particularly after complicated abdominal surgery and in the presence of severe sepsis or septic shock. Risk factors for developing CP include upper gastrointestinal tract perforation, Candida colonization, tertiary peritonitis, the severity of disease, premorbid conditions, cardiovascular failure, total parenteral nutrition, any drain/line breaching normally sterile barriers, development of peritonitis in the hospital, abdominal surgery and previous antibiotic therapy. Laboratory diagnosis primarily relies on histopathological diagnosis and culture-based methods. The usefulness of new diagnostic tests designed to identify immunogenic structures of fungal components or polymerase chain reaction for the detection of nucleic acids is still under investigation. Concerning treatment of invasive Candida infections echinocandins are recommended as first-line agents in most critically ill patients while fluconazole is still appropriate to prevent invasive fungal infections in peritonitis patients. Definitive antifungal therapy should be chosen based on susceptibility analyses.

CONCLUSION: Besides skilled surgical management, the decision for empirical antifungal treatment in any patient with suspected CP has to be based on the exact knowledge regarding origin, type of peritonitis, severity of disease, knowledge of patient specific risk factors and previous exposure to antibiotics or azole antifungals.