Antifungal Therapy in the Surgical Patient

Abstract

Fungal infections are an increasing problem in hospitalized surgical patients. These infections are frequently seen in critically ill surgical patients, with bloodstream infection the most common etiology. These infections are caused by a variety of species, including Candida, Aspergillus, Cryptococcus, mucormycosis, and emerging pathogens such as Fusarium. Superficial fungal infections are rarely dangerous and frequently treatable with a topical agent. In contrast, invasive fungal infections continue to be associated with serious complications and high mortality. Surgical patients frequently have many of the risk factors associated with invasive fungal infection, including critical illness, recent abdominal surgery, solid organ transplantation, exposure to broad-spectrum antibiotics, and any additional immunocompromised states. There are three main classes of antifungal agents, and their use should be tailored to the species isolated. Azoles are the most frequently used class, and fluconazole is the most frequently used antifungal; however, care should be taken as azole-resistant species are increasing in frequency. Amphotericin B should be reserved for critically ill patients with resistant organisms. Specific fungal diseases occur in surgical patients, including candidemia, intraabdominal fungal infection, and aspergillosis. Immunocompromised patients, including postoperative organ transplant recipients, are at particularly high risk of invasive fungal infections. Surgeons may be involved in the care of patients with invasive fungal infections in many settings, from debridement of infected tissue to treatment in a critical care unit. This chapter summarizes fungal infections typically encountered, with special emphasis on the use of antifungal therapy as treatment.