The Role of Candida in Abdominal Sepsis

The management of intra-abdominal candidiasis is a challenging issue. Differentiation between colonization and infection is a complex process, which has led to the development of several clinical scores and non-microbiologic tools over recent years. The distinction between colonization and infection is of major importance, as Candida infection is a proven risk factor for mortality in critically ill patients and patients with postoperative peritonitis. The most common pathogens cultured from surgical samples are Candida albicans and, among Candida non-albicans species, C. glabrata, and both of these organisms are also gut commensals in healthy subjects. However, candidemia is rare in these cases. The key issues for the management of these difficult cases are time efficiency and quality of both surgical and medical therapy. Source control is obviously a crucial factor, and the efficacy of source control is reinforced by antifungal therapy. Adequate antifungal therapy requires correct timing, an efficient spectrum, and the right dosage. In critically ill patients and those suspected of harboring azole-resistant strains, a general agreement among the experts and most of the recently published consensus recommends the use of echinocandins, while fluconazole is reserved for low-severity cases and patients with no previous antifungal therapy. Antifungal stewardship is based on de-escalation therapy when possible and limited duration of treatment.