Prospective Study
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World J Gastroenterol. Sep 14, 2014; 20(34): 12260-12268
Published online Sep 14, 2014. doi: 10.3748/wjg.v20.i34.12260
Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis
Philipp Lenz, Franziska Eckelskemper, Thomas Erichsen, Tim Lankisch, Alexander Dechêne, Gabriele Lubritz, Frank Lenze, Torsten Beyna, Hansjörg Ullerich, Andre Schmedt, Dirk Domagk
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
Thomas Erichsen, Tim Lankisch, Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30625 Hannover, Germany
Alexander Dechêne, Department of Gastroenterology and Hepatology, University Hospital Essen, 45147 Essen, Germany
Gabriele Lubritz, Institute of Medical Microbiology, University Hospital Muenster, D-48149 Muenster, Germany
Author contributions: Lenz P contributed to the design of the study, analysis and interpretation of data, statistical analysis, drafting of the manuscript; Eckelskemper F contributed to the acquisition of data; Erichsen T, Lankisch T, Dechêne A and Lubritz G contributed to the acquisition of data, contribution to the manuscript with important intellectual content; Beyna T, Ullerich H, Schmedt A and Lenze F contributed to the acquisition of data; Domagk D contributed to the study design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, study supervision.
Supported by An Investigator-Initiated Studies Program of MSD Sharp and Dohme GmbH and a research fellowship (to Lenz P) from the Faculty of Medicine, Westfaelische Wilhelms-Universität Muenster
Correspondence to: Philipp Lenz, MD, Department of Medicine B, University of Muenster, Albert-Schweitzer-Campus 1, Building A1, D-48149 Muenster, Germany. lenzph@uni-muenster.de
Telephone: + 49-251-8349509 Fax: + 49-251-8347570
Received: November 14, 2013
Revised: January 14, 2014
Accepted: April 27, 2014
Published online: September 14, 2014
Abstract

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.

Keywords: Cholangitis, Biliary candidiasis, Invasive fungal infection, Biliary obstruction

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.