The Surgical Infection Society Multicenter Observational Study: Antifungal Coverage after Gastrointestinal Perforation

Author(s):
Wardah Rafaqat; Mira Ghneim; Seema Anandalwar; Cynthia Susai; Nathan Alcasid; Geoffrey A. Anderson; Alexander J. Ordoobadi; Erik J. Teicher; David P. Blake; Brendin B. Jones; Sabrina Sanchez; Christopher Guidry; Pedro Teixeira; Jonathan Meizoso; Brianna L. Collie; Sarah McWilliam; Patrick McGonagill; Nicole D. Nitschke; Colette Galet; Lilian Nefcy; Jeffrey Johnson; Michael P. DeWane; Joseph Cuschieri; Amber Himmler; Jennifer Rickard; Jonathan Gipson; April Mendoza

Background:

Empiric antifungals are frequently administered in patients with gastrointestinal perforations, but there is limited evidence of their benefit.

Hypothesis:

We hypothesized that antifungals would offer no clinical benefit when compared to a standard course of antimicrobial therapy.

Methods:

A multicenter prospective cohort study included patients ≥18 years old undergoing operative management for gastrointestinal perforations from multiple etiologies admitted to 17 centers between August 2021 and January 2024. We excluded patients who were taking antifungal therapy for another reason at the time of operative management and/or patients with positive preoperative fungal cultures. Our primary outcome was organ-space infections. We performed a sub-group analysis among patients with spontaneous upper gastrointestinal perforations. We used a backward stepwise regression model to identify predictors of an organ-space infection.

Results:

A total of 313 patients were included; 133 (42.5%) received antifungal therapy, and 49 (15.7%) developed an organ-space infection. Regression analysis showed that drain placement and preoperative shock were associated with increased odds of developing an organ-space infection. Neither duration of antibiotic use (≤5 days vs. >5 days) nor antifungal use affected the primary outcome. In the sub-group analysis of 113 patients, preoperative mechanical ventilation was a predictor of organ-space infections, while perioperative proton pump inhibitor use was protective. (Table 1)

Conclusions:

Empiric use of antifungals was not associated with a decrease in intra-abdominal organ-space infections in patients with gastrointestinal perforations.