The Critical Role of Biliary Candidiasis in Development of Surgical Site Infections after Pancreatoduodenectomy: Results of Prospective Study Using a Selective Culture Medium for Candida Species.

Hiroyuki Kato,Masanobu Usui,Hiroyuki Sakurai,Kazuyuki Gyoten,Akihiro Tanemura,Kei Nakamura,Naohisa Kuriyama,Shuji Isaji,Yusuke Iizawa,Yoshinori Azumi,Takehiro Fujii,Aoi Hayasaki,Shugo Mizuo,Yasuhiro Murata,Masashi Kishiwada

doi:10.1155/2018/5939724

Abstract

In accordance with previous reports, the incidence of biliary candidiasis (BC) after pancreaticoduodenectomy (PD) was reported to be 0 to 5%, and the clinical significance of BC still has been elusive. In this study, we prospectively evaluated the precise incidence of BC after PD using the CHROMagar Candida plate in an attempt to elucidate whether BC has a significant impact on the clinical outcomes after PD. Patients and Method. From November 2014 to March 2016, the consecutive 51 patients who underwent PD were enrolled for this study. The bile juice was prospectively collected through the biliary stent tube on postoperative days (POD) 3, 7, and 14 and directly incubated onto the CHROMagar Candida plate for the cultivation of various Candida species. In the presence or absence of BC, we compared the incidence of SSIs. Results. The incidence of postoperative BC was 15% on POD 3, 24% on POD 7, and 39% on POD 14, respectively. Taken together, 22 patients out of 51 (43.1%) developed BC after PD. Moreover, the incidence of SSIs was significantly higher in patients with BC than in those without it (71% versus 7%, p=0.005). BC was selected as the only significant risk factor of SSIs after PD among the various risk factors. Even though a cause of BC is unknown, high level of alkaline phosphatase (cut-off line >300 IU/L) was selected as the only preoperative risk factor of the development of BC. Conclusion. We elucidated new evidence in which BC could be the independent cause of SSIs after PD and should not be recognized as just contamination artifacts. Preoperative assessment for identifying carriers of Candida species might be essential for reducing the incidence of SSIs after PD.

Highlights

Candida species play a critical role in nosocomial, catheter, and skin infections in recent years, especially in patients with malignancies, long-term antibiotic therapy, diabetes mellitus with multiorgan complications, intensive care unit (ICU) admission, immunosuppressive drugs, and posttransplant status [1,2,3,4]
Our prospective study newly revealed the following 3 things: (1) the incidence of biliary candidiasis (BC) after PD was 43.1% when Candida specific plate was used, and it was considered to be higher incidence compared to previous reports [8, 9]. (2) BC potentiates the incidence of SSIs after PD and was selected as the most influential risk factor of SSIs. (3) The precise etiology of BC was still unknown, but preoperative high ALP levels and prolonged PT-INR on postoperative days (POD) 1 were significantly related to the development of BC
Sudo et al reported that prophylactic antibiotics effectively targeted approximately 30% of bile microorganisms in patients with preoperative biliary drainage and recommended the perioperative usage of antibiotics according to the result of preoperative biliary culture [8]

Summary

Introduction

Candida species play a critical role in nosocomial, catheter, and skin infections in recent years, especially in patients with malignancies, long-term antibiotic therapy, diabetes mellitus with multiorgan complications, intensive care unit (ICU) admission, immunosuppressive drugs, and posttransplant status [1,2,3,4]. Even though the importance of Candida infections has been increasing in recent years, impact of biliary candidiasis (BC) on complications after pancreaticoduodenectomy (PD) and its incidence are still unknown. Our retrospective study newly revealed that the incidence of patients with BC frequently developed severe infectious complications including abscess formation compared with patients without BC, and Candida species in bile juice was identified as the independent risk factors of SSIs after PD [6]. These results made us reconsider a significance. Our previous study has potential limitations because the study retrospectively assessed the patients who underwent PD, resulting in high selection bias and made us conduct the further prospective study

Objectives

Results

Conclusion