title: Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis.
abstract: OBJECTIVE
  To develop an algorithm to improve the diagnosis and treatment of patients with biliary candidiasis.
  
  
  METHODS
  We performed a prospective study of 127 patients who underwent endoscopic retrograde cholangiopancreatography, for various biliary disorders, at 3 tertiary referral centers in Germany from July 2011 through July 2012 (ClinicalTrials.gov: NCT01109550). Bile, buccal, and stool samples were collected. When indicated, endoscopic transpapillary bile duct biopsies were performed to clarify the etiology of bile duct strictures and to prove invasive fungal infections.
  
  
  RESULTS
  Candida species were detected in 38 of the 127 bile samples (29.9%). By multivariate analysis patients' age and previous endoscopic sphincterotomy were independent risk factors for biliary candidiasis (P < 0.05). Patients with immunosuppression (P = 0.058) and recent long-term antibiotic therapy (> 7 d) (P = 0.089) tend to be at risk for biliary candidiasis. One patient was negative in mycological culture of bile fluid but invasive biliary candidiasis was diagnosed histologically. Of Candida subspecies detected, 36.7% were azole-resistant, such as C glabrata. Eight patients received anti-mycotic therapy, based on our algorithm. Of these, 3 had cancer with biliary tract involvement, 2 had secondary sclerosing cholangitis, 1 had retroperitoneal fibrosis, and 5 had septicemia. In all patients contamination was ruled out by smears of the endoscope channel.
  
  
  CONCLUSIONS
  Gastroenterologists should be aware of frequent candida colonization in patients with cholangitis and biliary disorders. Our suggested algorithm facilitates the further clinical management.
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Lenz
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Franziska
authors.initials: F
authors.lastname: Eckelskemper
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Erichsen
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Tim
authors.initials: T
authors.lastname: Lankisch
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Dechêne
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Lubritz
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Lenze
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Torsten
authors.initials: T
authors.lastname: Beyna
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Hansjörg
authors.initials: H
authors.lastname: Ullerich
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Andre
authors.initials: A
authors.lastname: Schmedt
authors.affiliation: Philipp Lenz, Franziska Eckelskemper, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk, Department of Medicine B, University of Muenster, D-48149 Muenster, Germany.
authors.forename: Dirk
authors.initials: D
authors.lastname: Domagk
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D000935:Antifungal Agents / Q000627:therapeutic use; D001431:Bacteriological Techniques; D001646:Bile / Q000382:microbiology; D001706:Biopsy; D002175:Candida / Q000187:drug effects / Q000302:isolation & purification*; D002177:Candidiasis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D016009:Chi-Square Distribution; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002761:Cholangitis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D002779:Cholestasis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D003251:Constriction, Pathologic; D019091:Critical Pathways; D005243:Feces / Q000382:microbiology; D005260:Female; D005858:Germany; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009061:Mouth Mucosa / Q000382:microbiology; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D012307:Risk Factors; D062606:Tertiary Care Centers
chemical_list: D000935:Antifungal Agents
keywords: Biliary candidiasis; Biliary obstruction; Cholangitis; Invasive fungal infection