Fungal Infections in Severe Acute Pancreatitis

Rakesh Kochhar; Mohd Talha Noor; Jaidev Wig

Disclosures

J Gastroenterol Hepatol. 2011;26(6):952-959. 

In This Article

Abstract and Introduction

Abstract

Severe acute pancreatitis (SAP) is associated with significant morbidity and mortality. The majority of deaths related to SAP are the result of infectious complications. Although bacterial infections are most commonly encountered, fungal infections are increasingly being recognized. Candida is the most common fungal infection. The occurrence of fungal infection in patients with acute pancreatitis adversely affects the clinical course, leading to a higher incidence of systemic complications, and possibly mortality as well. Important risk factors for fungal infection in patients with acute pancreatitis include broad-spectrum antibiotics, prolonged hospitalization and surgical/endoscopic interventions, use of total parenteral nutrition, and mechanical ventilation. Patients with higher severity of pancreatitis are at a greater risk. The pathogenesis of fungal infection in patients with acute pancreatitis is multifactorial. Translocation of microorganisms across the gut epithelium, lymphocyte dysfunction, and the virulence of the invading microorganisms play important roles. Histological demonstration of fungi remains the gold standard of diagnosis, but a positive biopsy is rarely obtained. The role of biomarkers in the diagnosis is being investigated. As early diagnosis and treatment can lead to improved outcome, a high index of suspicion is required for prompt diagnosis. Limiting the use of broad-spectrum antibiotics, early introduction of enteral nutrition, and timely change of vascular catheters are important preventive strategies. The role of antifungal prophylaxis remains controversial. Surgical necrosectomy with antifungal therapy is the most widely used treatment approach. Clinical trials on antifungal prophylaxis are needed, and indications for surgical intervention need to be clearly defined.

Introduction

Infectious complications are the major cause of morbidity and mortality in patients with severe acute pancreatitis (SAP), with bacterial infections being the most widely recognized and reported.[1] Their occurrence correlates with the extent of necrosis, as well as the duration of pancreatitis, and they can adversely influence the clinical course of SAP.[2] In recent years, fungal infections have been increasingly recognized. The purpose of this study is to discuss the incidence, pathogenesis, and risk factors of fungal infections in patients with SAP. In addition, diagnosis, prognosis, treatment, and the role of prophylaxis are also discussed. For this study, a thorough literature search was performed on PubMed using a variety of combinations of key words, such as "fungal infection", "severe acute pancreatitis", "antifungal prophylaxis", and "pancreatic fungal infection".

Fungal infections in critically-ill patients have been increasing in recent times. Surveillance studies have shown that the incidence of fungal infections varies greatly between different types of intensive care units (ICU).[3] In general, ICU caring for high-risk patients, such as abdominal surgical or immunosuppressed patients, have a higher incidence of invasive candidiasis than general medical/surgical ICU.[4,5]

SAP with systemic inflammatory response is a serious illness predisposing patients to infections. The prevalence of fungal infection in acute pancreatitis ranges from 7% to 41%, and invasive candidiasis is associated with mortality > 40%.[1,6–18] Pancreatic necrosis with poor perfusion of the pancreatic tissue makes eradication of fungal infection difficult. Recent studies have suggested that early diagnosis and proper therapy of fungal infections in patients with acute pancreatitis can lead to improved outcome.[1,15]

Primary and Secondary Fungal Infection

Pancreatic fungal infection is classified as primary if the positive culture is obtained at the time of initial radiologic, endoscopic, or surgical intervention, and secondary if obtained following a prior intervention.[7,10,12] Concomitant bacterial infections with Gram-positive bacteria are more common in patients with primary Candida infection, while infections with Gram-negative bacteria are more common in patients with secondary infection.[6] Mortality is higher among patients with secondary pancreatic fungal infection, as compared to those with primary fungal infection.[17] The prevalence of primary fungal infection ranges from 7% to 17%, while that of secondary pancreatic infection ranges from 4% to 32%.[7–11,19,20]

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