Pre-operative Antifungal Therapy Does Not Improve Outcomes in Perforated Peptic Ulcers

Author(s):
Christopher Horn; Adrian Coleoglou Centeno; Nicholas Fiore; Qiao Zhang; Rohit Rasane; Daniel Kaufman; Marlon Torres; John Mazuski; Obeid Ilahi; Laurie Punch; Grant Bochicchio

Background:

With the advent of anti-Helicobacter pylori therapy, complications of  peptic ulcer disease (PUD)  have declined significantly since the 1990s. Despite this, operative treatment of PUD is one of the most commonly performed emergency general surgeries. While previous papers suggest that isolation of Candida from peritoneal fluid cultures may be associated with worse outcomes in patients with perforated peptic ulcers (PPUs), post-operative antifungal therapy has not been shown to be effective. There have been no studies of preoperative antifungal therapy in PPU.

Hypothesis:

We hypothesized that preoperative antifungals improve post-operative outcomes in patients with perforated peptic ulcer disease undergoing operative management.

Methods:

A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including over 7,000 patients was queried for patients with PPUs. Demographics and clinical outcomes were abstracted. Preoperative antifungal use, intraoperative peritoneal fluid cultures and post-operative infections were manually abstracted. We compared outcomes and presence of fungal infections between patients receiving perioperative antifungals in the entire cohort and in patients with fungal isolates from intraoperative peritoneal fluid cultures. Chi-squared and Fisher’s exact test were used to compare categorical variables. Student’s T-test was used for continuous variables.

Results:

There were 107 patients with perforated peptic ulcers treated with operative management; 27 (25.2%) received preoperative antifungal therapy. There were no differences in demographics or comorbidities. 33 patients received peritoneal fluid culture; 17 (51.5%) cultures were positive for fungus. Isolation of fungus from in peritoneal fluid culture did not affect outcomes. There were no differences in length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, 30-day readmission rates or rates of intraabdominal abscess formation or fungemia in patients who received preoperative antifungals regardless of the isolation of fungi in the peritoneal fluid.

Conclusions:

Historically, Candida has been noted to occur in 29%– 57% of peritoneal fluid cultures in patients with PPUs, however there are no studies evaluating preoperative antifungal therapy in PPUs. This data suggests that preoperative antifungals may not improve outcomes in patients undergoing operative management for perforated peptic ulcers.