In perforated peptic ulcer, a subset of patients faces substantially elevated risk for fungal superinfection. Identifying these patients and addressing antifungal coverage is a distinct management consideration within this population.
Antifungal therapy is indicated in patients with perforated peptic ulcer who carry one or more of the following risk features:
Antifungal therapy is the cornerstone of management in this scenario. The protocol addresses which class of antifungal agent is appropriate — choices differ based on illness severity, prior antifungal exposure, and local resistance considerations. A fallback option is also defined for cases of intolerance or agent unavailability. The complete selection algorithm and criteria are available in the full protocol.
Antifungal should be administrated in patients at high risk for fungal infection (e.g., immunocompromised, advanced age, comorbidities, prolonged ICU-stay, unresolved intra-abdominal infections) (weak recommendation based on low-quality evidences, 2C)
Fluconazole (LD 12 mg/kg BW-800 mg; MD 6 mg/kg/ day) should be given in critically ill patients, with community-acquired Candida peritonitis, no prior azole exposure, low-risk for infections with fluconazole-resistant Candida spp., as prophylaxis to prevent invasive infections
Echinocandin antifungals are recommended as first-line therapy for invasive infections, and candidemia in non-neutropenic critically ill patients
Amphotericin B (3–5 mg/day) should be considered if alternative therapy is not available or in case of intolerance to echinocandin or azoles
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