Garbino, J.

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1690 • CID 2005:41 (1 December) • CORRESPONDENCEFigure 1. Distribution of Candida albicans and non-albicans species of Candida (C. non-albicans)before and after the study.the epigastrium. Blood tests revealed leu-kocytosis (WBC count, cells/L,98.29 10with 78.2% polymorphonuclear leuko-cytes) and an elevated C-reactive proteinlevel (6.47 mg/dL). The biliary enzymelevels were within the normal limits (al-kaline phosphatase, 226 U/L; g-glutamyltranspeptidase, 203 U/L). Urinary tract in-fection was the tentative diagnosis, andtreatment with cephalosporin and genta-micin was started.Abdominal ultrasonography revealed alobulated, hypoechoic, cystic lesion in thelateral segment of the left hepatic lobe. Theabdominal CT showed a 5-cm heteroge-neous, septated, nodular lesion with mar-ginal enhancement, a finding compatiblewith pyogenic liver abscess. However, alinear radiopaque density within the lesionwas also noted (figure 1 top, arrow). Theantibiotic therapy was changed to cefo-tiam and metronidazole. The fever becamelow-grade, and the antibiotic therapy waschanged to ampicillin-sulbactam becauseof a decreased hemoglobin level, plateletcount, and WBC count, which were prob-ably adverse effects of cephalosporintherapy.The patient became afebrile after 7 daysof intravenous antibiotic therapy. Cultureof a specimen from percutaneous tran-shepatic abscess aspiration revealed Kleb-siella pneumoniae and aerobic, gram-pos-itive bacilli. In accordance with thefindings of the drug susceptibility test, thecourse of antibiotics was changed toamoxicillin-clavulanate. After 15 days ofhospitalization, the patient was dischargedin a stable condition. During the following2 years, no associated symptoms or signsrecurred. A CT scan performed at a fol-low-up visit at 2 years showed that theforeign body remained in the left liver butthere was no adjacent inflammation (fig-ure 1, bottom).At least 10 cases of hepatic abscess dueto an ingested fish bone have been re-ported [1–5]. Treatments included drain-age of the abscess, removal of the foreignbody, and administration of appropriateantibiotics. All reported cases were treatedwith either percutaneous transhepatic re-moval or surgical removal of the fish bone.If there is a strong suspicion of bowel per-foration by a foreign body or if a foreignbody is detected preoperatively, surgery isconsidered the treatment of choice in cur-rent clinical practice [6, 7]. To the best ofour knowledge, this is the first docu-mented case of a hepatic abscess secondaryto fish bone penetration that was success-fully treated without removal of the for-eign body. We thus recommend that med-ical approaches could be attempted firstin such cases, especially when contrain-dications for surgery exist.AcknowledgmentsPotential conflicts of interest. All authors: noconflicts.Chung-Yi Yang,1 Jia-Horng Kao,2Kao-Lang Liu1, and Shyh-Jye Chen1Departments of 1Medical Imaging and 2InternalMedicine, National Taiwan University Hospitaland National Taiwan UniversityCollege of MedicineReferences1. Nisbet M, Thomas M. Liver abscess associatedwith persistent Streptococcus anginosus bacter-emia. Clin Infect Dis 2005; 41:352–3, 403–5.2. Horii K, Yamazaki O, Matsuyama M, Higaki I,Kawai S, Sakaue Y. Successful treatment of ahepatic abscess that formed secondary to fishbone penetration by percutaneous transhepaticremoval of the foreign body: report of a case.Surg Today 1999; 29:922–6.3. de la Vega M, Rivero JC, Ruiz L, Suarez S. Afish bone in the liver. Lancet 2001; 358:982.4. Kessler AT, Kourtis AP. Images in clinical med-icine: liver abscess due to Eikenella corrodensfrom a fishbone. N Engl J Med 2001; 345:e5.5. Theodoropoulou A, Roussomoustakaki M,Michalodimitrakis MN, Kanaki C, Kourou-malis EA. Fatal hepatic abscess caused by a fishbone. Lancet 2002; 359:977.6. Bee DM, Citron M, Vannix RS, et al. Delayeddeath from ingestion of a toothpick. N Engl JMed 1989; 320:673.7. Dugger K, Lebby T, Brus M, Sahgal S, LeikinJB. Hepatic abscess resulting from gastric per-foration of a foreign object. Am J Emerg Med1990; 8:323–5.Reprints or correspondence: Dr. Kao-Lang Liu, Dept. of Med-ical Imaging, National Taiwan University Hospital and Na-tional Taiwan University College of Medicine, No. 7 ChungSan South Rd., Taipei 100, Taiwan (wgl@ntumc.org).Clinical Infectious Diseases 2005; 41:1689–90 2005 by the Infectious Diseases Society of America. Allrights reserved. 1058-4838/2005/4111-0030$15.00Fluconazole Prophylaxis forCritically Ill Patients at HighRisk for Candida InfectionSir—I have read with interest the articleby Wenzel and Gennings [1] recently pub-lished in a supplement of the journal. Inthis article, the authors comment on thestrategy followed at the Johns HopkinsUniversity Hospital for patients in criticalcare units who are at particularly high riskfor Candida infection, which is to giveprophylactic anti-Candida antibiotics toall patients expected to be in an intensivecare unit for 3 days. This strategy hasbeen shown to reduce the overall rate ofcandidal infections in a study that ex-amined all anatomic sites, but it did notreduce mortality in a surgical intensivecare unit at Johns Hopkins UniversityHospital [2]. However, only 1 patient re-ceiving fluconazole developed a candidalbloodstream infection, and 2 patients re-ceiving placebo developed infection of theblood and the peritoneum [1].CORRESPONDENCE • CID 2005:41 (1 December) • 1691In a study conducted in our institutionthat invovled critically ill patients at highrisk for development of candidal infec-tions, patients were randomly assigned toreceive fluconazole at a dosage of 100 mgdaily ( ) or placebo ( ) [3].np 103 np 101Candidal infections occurred less fre-quently in the fluconazole group than inthe placebo group (5.8% vs. 16% of pa-tients; rate ratio, 0.35; 95% CI, 0.11–0.94).Approximately 90% of candidemia epi-sodes occurred in the placebo group (rateratio for fluconazole use, 0.10; 95% CI,0.02–0.74). The crude mortality rate inboth groups was similar. In conclusion,our results demonstrate that, for selectedcritically ill patients at high risk, flucon-azole prophylaxis decreases the incidenceof candidal infection, and of candidemia,in particular.We did not observe changes in the pat-terns of distribution of infection due toCandida albicans and infection due tonon-albicans species of Candida when wecompared the species distribution beforeand after the study [4] (figure 1). Nev-ertheless, we would recommend close sur-veillance for the emergence of antifungalresistance.AcknowledgmentsPotential conflicts of interest. J.G.: noconflicts.J. GarbinoDivision of Infectious Diseases, University Hospitalsof Geneva, Geneva, SwitzerlandReferences1. Wenzel RP, Gennings G. Bloodstream infec-tions due to Candida species in the intensivecare unit: identifying especially high-risk pa-tients to determine prevention strategies. ClinInfect Dis 2005; 41(Suppl 6):S389–93.2. Pelz RK, Hendrix CW, Swoboda SM, et al. Dou-ble-blind placebo-controlled trial of flucona-zole to prevent Candida infections in criticallyill surgical patients. Ann Surg 2001; 233:542–8.3. Garbino J, Lew DP, Romand JA, Hugonnet S,Auckenthaler R, Pittet D. Prevention of severeCandida infections in nonneutropenic, high-risk, critically ill patients: a randomized, dou-ble-blind, placebo-controlled trial in patientstreated by selective digestive decontamination.Intensive Care Med 2002; 28:1708–17.4. Garbino J, Rohner P, Romand J-A, Lew D, Pit-tet D. Candidemia at the ICU of a tertiary carehospital. Int J Infect Dis 2004; 8(S1):S133.Reprints or correspondence: Dr. J. Garbino, Div. of InfectiousDiseases, University Hospitals of Geneva, 24 Rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland (jorge.garbino@hcuge.ch).Clinical Infectious Diseases 2005; 41:1690–1 2005 by the Infectious Diseases Society of America. Allrights reserved. 1058-4838/2005/4111-0031$15.00

Fluconazole Prophylaxis for Critically Ill Patients at High Risk for Candida Infection

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