Published online Sep 14, 2014. doi: 10.3748/wjg.v20.i34.12260
Revised: January 14, 2014
Accepted: April 27, 2014
Published online: September 14, 2014
Processing time: 311 Days and 0.8 Hours
AIM: 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.
CONCLUSION: Gastroenterologists should be aware of frequent candida colonization in patients with cholangitis and biliary disorders. Our suggested algorithm facilitates the further clinical management.
Core tip: This prospective multicenter study evaluates the clinical impact of microbial analysis of bile fluid in diagnosing biliary candidiasis. Additionally, a diagnostic algorithm is established to facilitate the clinical management and to improve antimicrobial therapy in patients with cholangitis and involvement of fungal species.