title: The impact of systemic fungal infection in patients with perforated oesophagus.
abstract: BACKGROUND
  Perforated oesophagus is a surgical emergency with significant morbidity and mortality. Systemic fungal infection represents a poor response to the magnitude of the insult, which adds significantly to the risk of morbidity and mortality in these patients. We reviewed our  experience with this group of patients over a six-year period in a tertiary referral centre.
  
  
  METHODS
  A retrospective clinical review was conducted of patients who were admitted following a ruptured oesophagus over a period of six years (January 2002 - January 2008).
  
  
  RESULTS
  We had 27 admissions (18 men and 9 women) following an isolated perforated oesophagus to our unit. The median patient age was 65 years (range: 22-87 years). The majority (n=24, 89%) presented with spontaneous perforations (Boerhaave's syndrome) and three (11%) were iatrogenic.  Fungal organisms, predominantly Candida albicans, were positively cultured in pleural or blood samples in 16 (59%) of the 27 patients. Fourteen patients grew yeasts within the first seven days while two showed a delayed growth after ten days. Overall mortality was 5 out of 27 patients  (19%). There was no mortality among the group that did not grow yeasts in their blood/pleural fluid while mortality was 31% (5/16) in the group with systemic fungal infection (p<0.001). A positive fungal culture was also associated with increase ventilation time, intensive care unit  stay and inpatient hospital stay but not an increased rate of complications.
  
  
  CONCLUSIONS
  Systemic fungal infection in patients with a ruptured oesophagus affects a significant proportion of these patients and carries a poor prognosis despite advanced critical care interventions. It may  represent a general marker of poor host response to a major insult but can add to mortality and morbidity. It is worth considering adding antifungal therapy empirically at an early stage to antimicrobials in patients with an established diagnosis of a perforated oesophagus.
authors.affiliation: Liverpool Heart and Chest Hospital NHS Foundation Trust, UK. drhany.elsayed@yahoo.co.uk
authors.forename: H
authors.initials: H
authors.lastname: Elsayed
authors.forename: H
authors.initials: H
authors.lastname: Shaker
authors.forename: I
authors.initials: I
authors.lastname: Whittle
authors.forename: S
authors.initials: S
authors.lastname: Hussein
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000935:Antifungal Agents / Q000627:therapeutic use; D003422:Critical Care / Q000379:methods; D042241:Early Diagnosis; D004939:Esophageal Perforation / Q000175:diagnosis / Q000382:microbiology* / Q000601:surgery; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000935:Antifungal Agents