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Mannose-binding lectin deficiency facilitates abdominal yeast infection in patients with secondary peritonitis

MBL and abdominal yeast infection

Mannose-binding lectin deficiency facilitates abdominal yeast infection in patients with secondary peritonitis

Abstract
Mannose-binding lectin (MBL) deficiency due to variations in the MBL gene is associated with increased susceptibility to infections. In this study the association between MBL deficiency and the occurrence of abdominal yeast infection (AYI) was examined in peritonitis patients. Eighty-eight patients with secondary peritonitis, requiring emergency laparotomy, were included. MBL genotype (wild type (WT) vs. patients with variant genotypes), MBL plasma concentrations and Candida risk factors were examined in patients with and without AYI (positive abdominal yeast cultures during (re-) laparotomy)…….

Introduction
Secondary peritonitis is a clinical condition frequently observed in the surgical ward and the ICU(15). In spite of major advances in (intensive) care and antimicrobial therapy, mortality in peritonitis has remained approximately 25% for decennia (25,34). Morbidity in patients with peritonitis also tends to be extensive, with long hospital- and ICU-stay, and long periods of mechanical ventilation (25). Especially when peritonitis persists or recurs, not withstanding optimal management, and tertiary peritonitis develops, mortality increases to >50% (29)…..

Materials and Methods
1. Patients and controls
In this prospective cohort study, patients were included with peritonitis caused by perforation or infection of a visceral organ, by necrosis of part of the gastrointestinal tract or by postoperative peritoneal infection. Exclusion criteria were age < 18 and > 80 years, and acute pancreatitis. Patients were included when they underwent emergency laparotomy, referred to as the ‘index laparotomy’, in which peritonitis was confirmed macroscopically and microbiologically. Operative management of peritonitis comprised of elimination of the infectious focus and abdominal lavage with saline (0.9%).

Relaparotomy was performed in a planned setting or on demand (indicated by clinical deterioration or failure to improve). Controls for genotyping and plasma MBL concentrations were recruited from a population of healthy blood bank donors (n=97). The study was approved by the medical ethical committee and written informed consent was obtained from all patients or their legal representatives when appropriate.

2. Definitions
Abdominal yeast infection (AYI) was defined as positive yeast culture from abdominal fluid sampled during (re-) laparotomy with subsequent features of infection / SIRS (see below).

Yeast sepsis was defined as a positive culture from a sterile site, which could not have been contaminated directly, like blood or non-contiguous organs. Yeast colonization was defined as 1 or more positive yeast cultures from sputum, rectum, urine or wound surface.

Intensity of colonization is calculated by dividing the total of positive yeast cultures by the total of performed cultures (excluding blood cultures) as described by Pittet et al.(36).

Systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock (developing within 24 hours of enrollment in the study) were defined in accordance with the recommendations of the ACCP/SCCM Consensus Conference (4). Risk factors associated with Candida infection (36), Candida peritonitis (10,11) and Candidemia (3) in multivariate analysis, as mentioned in recent literature, were surveyed……

3. Sampling and measurements
During surgery cultures of abdominal fluid as well as blood were performed using a collection system for aerobic and anaerobic organisms (BacT/ALERT, Biomérieux, Durham, NC, USA). Postoperative cultures were performed routinely and to the discretion of the physician in charge of the patient. Standard empiric antibiotic treatment for severe peritonitis – received by all patients – consisted of a combination of amoxicillin, gentamycin and metronidazole. This regimen was adjusted according to culture results. When yeast was cultured fluconazole was the first antifungal agent of choice.

All patients received selective bowel decontamination orally as described by De Jonge et al.(8) (four times daily 0.5 g of an oral paste (containing 2% polymyxin E, 2% tobramycin, and 2% amphotericin B) and 100 mg polymyxin E, 80 mg tobramycin, and 500 mg amphotericin B administered through gastric tubes)…..

4. Sequence reactions
The genomic PCR products were sequenced in both orientations after clean-up with the Qiaquick PCR-purification kit (Qiagen GmbH, Hilden, Germany). Five µl of purified PCR product was used as template together with the sense or the antisense primer (250 nM) used to obtain this PCR product. Four µl of reaction mixture from the Big Dye Terminator cycle sequencing ready reaction kit v 1.1 (PE Applied Biosystems, Warrington, UK) were mixed with 2 µl of Big Dye Terminator dilution buffer in a total volume of 20 µl……..

5. Statistical analysis
Known yeast risk factors and MBL geno- and phenotype of peritonitits patients with abdominal yeast infection, initially or during the course of disease, were compared to peritonitis patients without abdominal yeast infection. Furthermore, the proportion of patients with a positive culture at index laparotomy or at relaparotomy (during course of the disease) was determined in relation to genotype. Results are presented as medians with inter-quartile range (IQR) or as quantities (n) with percentages……

Results
1. Patients
Eighty-eight consecutive peritonitis patients were included in this study. The etiology of peritonitis was perforation in 39 patients (44%), necrosis in 16 patients (18%) and anastomotic leakage in 28 patients (32%). Peritonitis originated from either the upper (stomach, duodenum and jejunum) or lower (ileum, colon, sigmoid and rectum) gastrointestinal tract in 14 and 74 patients, respectively. All patients had polymicrobial peritonitis with or without yeast. The antibiotic treatment was started empirically (cefuroximor amoxicillin) and gentamicin and metronidazole) in all patients. Antibiotic regimens were adapted if necessary after culture results became known……..

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