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Background Fungal infection is a devastating complication with an increased incidence in the past decade. Immune-depressed patients undergoing high-risk procedures have an increased incidence of surgical infection, particularly due to fungal colonization. Methods Twenty patients undergoing pancreas transplantation, 20 kidney transplant patients undergoing biliary tract surgery, 20 patients with human immunodeficiency virus (HIV) undergoing biliary tract surgery and 20 patients undergoing pancreatic resection for neoplasms were enrolled in a prospective study concerning perioperative surgical infection. All patients underwent surgical procedures by the same surgeon. All had preoperative blood counts, assay of CD lymphocyte populations, complete nutritional evaluation and similar antibiotic prophylaxis. Perioperative care was done to a similar standard and only patients undergoing pancreas transplantation received fungal prophylaxis (nystatin wash and swallow). In patients with clinical signs of infection, cultures were sent with special consideration to fungal infection. Results Two of the patients undergoing pancreas transplantation (one of whom died from disseminated candidiasis), three of the kidney transplant patients (two on the wound, one in the catheter), three patients with HIV (two on bile culture, one in the bloodstream) and one of the patients undergoing pancreatic resection (pancreatic fistula and bloodstream) had fungal infection. All patients had concomitant bacterial infections at the time of fungal infection (60 per cent Staphylococcus epidermidis). Patients with fungal infection had increased levels of immunosuppression with decreased CD4 recounts (pancreas transplants and patients with HIV), increased perioperative levels of blood glucose requiring insulin treatment, prolonged antibiotic therapy with broad-spectrum antibiotics (piperacillin–tazobactam), previous positive cultures from the bile of the biliary tract or the duodenum of the transplanted pancreas, and concomitant bacterial infections (especially opportunistic). Conclusion Surgical patients with positive cultures from surgical specimens, prolonged broad-spectrum antibiotic therapy and severely decreased lymphocyte immune function had an increased incidence of fungal infection with significant morbidity and mortality rates. Fungal prophylaxis is strongly recommended in these high-risk patients undergoing biliopancreatic tract surgery.

Background In previous studies the authors have selected patients and surgical procedures with a high risk of fungal infection. Whether these patients and procedures require fungal prophylaxis was studied. Methods From June to December 1999, 850 surgical patients from two university hospitals were enrolled in a prospective open randomized study. Fifty were selected according to demographics (age, sex, co-morbidity) and surgical procedures (defined by GDRs and ICD9-CM) as at high risk of fungal infection according to a previously defined algorithm (presented to the Surgical Infection Society of Europe 1999). In these 50 patients the CD lymphocyte population was recollected, and urine, blood, sputum and wound (if infected) cultures were performed. Then, 25 were treated with nystatin wash and swallow, and the others with placebo. Fungal infection and fungal colonization were defined and used as the endpoint of the study. Results Patients not selected for the study did not develop fungal infection. Of the high-risk patients, 20 presented with fungal colonization (12 urine, seven wound and five bloodstream cultures) and 12 presented with subsequent fungal infections. Of these 20 colonized patients, only those with nystatin prophylaxis did not require fungal treatment, whereas controls required treatment. CD4 lymphocyte recount (below 300) was uniformly decreased in all patients with fungal infection. Conclusion Immunodepressed patients at high risk with concomitant fungal colonization develop fungal infections 2–5 days after high-risk surgical procedures. Nystatin prophylaxis in such patients may reduce the degree and severity of fungal infection. If fungal colonization is present and the CD4 lymphocyte count is below 300, fungal treatment might be advisable.