When should prophylactic antifungal coverage be considered for pancreatic necrosis?

The Bottom Line:

Prophylactic antifungal coverage should be considered in all severely ill surgical patients with multiple risk factors for invasive candidiasis due to the substantial and convincing data for its efficacy.

Reference:

Howard TJ. The role of antimicrobial therapy in severe acute pancreatitis.3(3):585-93.  Surg Clin North Am. 2013 Jun;9.

Summary:

Much less clear at present is whether the recommendations for Candida prophylaxis in surgical patients should be broadened to include their use in severely ill patients with pancreatic necrosis.  Patients with yeast on Gram’s stain following CT-guided FNA or direct culture at the time of necrosectomy should receive fluconazole targeted at Candida albicans, the most common fungal isolate in secondary pancreatic infections. Candida glabrata, which has a higher MIC for fluconazole than C albicans, should be treated either with a higher dose of fluconazole (400 mg/d) to achieve greater concentrations in the pancreas, or caspofungin. Those patients who have been treated with fluconazole prophylactically and subsequently develop infected necrosis with yeast should be treated with caspofungin.

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