A 50-year-old man with perforated colon cancer and sepsis underwent surgery but remained febrile and leukocytic despite antibiotics. Blood cultures grew Candida glabrata, which may be resistant to fluconazole. The patient is at risk of fungal infection due to recent surgery, antibiotics, TPN, and exposure to fluconazole. Voriconazole, amphotericin B or caspofungin would be started while awaiting sensitivities as C. glabrata may not respond to fluconazole. An echocardiogram is recommended to check for vegetations which could influence antifungal treatment duration and prognosis.

1. Complicated intra-abdominal
infection
Dr.(Prof) Santosh Kumar Bhaskar

2. A 50-year-old man presents to hospital with fever and an acute
abdomen. He undergoes an emergency laparotomy, the findings of
which include perforated carcinoma in the splenic flexure and
generalized faecal soiling of the peritoneum. He undergoes a left
hemicolectomy with a defunctioning colostomy. Post-operatively he is
transferred to the intensive care unit because of septic shock.
What antibiotic regimen will you consider and why?

3. Triple therapy or Timentin or Tazocin – cover enterococcus, gram
negatives and anaerobes.
May consider adding empiric fluconazole
Vancomycin, gentamicin, metronidazole if penicillin allergic
Despite a five-day course of antibiotics he remains unwell with fever up
to 38.50C, WCC 16.7 x 109 /l. He is unable to tolerate oral feeds and is
on TPN.

4. Literature support for single antibiotic vs combination
therapy in surgical patients

5. Literature support for single antibiotic vs combination
therapy in surgical patients

6. List the likely abdominal causes of persistent fever and
leukocytosis?
Intra-abdominal collection
Wound infection
Acalculous cholecystitis
Pancreatitis
Stomal necrosis
Blood cultures show Candida glabrata in one of the three bottles.

7. Predisposing factors for this infection in this patient.
Malignancy
Abdominal soiling (repeated abdominal surgery)
TPN
Recent broad spectrum antibiotic therapy
Indwelling CVC
Exposure to fluconazole
Diabetes
Renal failure

8. Literature support for risk factors for fungal infection

9. What antibiotic therapy will you commence whilst waiting for
sensitivities and why?
Voriconazole or amphotericin B or caspofungin
Candida glabrata may not be sensitive to fluconazole

10. Based on the culture report, give one other investigation, the
results of which might influence the prognosis and duration of
antifungal treatment, and the rationale for your choice.
Echocardiography – vegetations
CT / USS abdomen – liver abscess
Ophthalmic examination – retinal abscesses

11. 2013 WSES guidelines for management of
intra-abdominal infections

12. 2013 WSES guidelines for management of
intra-abdominal infections

13. 2013 WSES guidelines for management of
intra-abdominal infections

14. 2013 WSES guidelines for management of
intra-abdominal infections

15. 2013 WSES guidelines for management of
intra-abdominal infections

16. 2013 WSES guidelines for management of
intra-abdominal infections

17. OR