Candida esophagitis following cardiac operation and short-term antibiotic prophylaxis

Dysphagia and retrosternal pain are common complaints in patients after cardiac operations, and most often they result from the median sternotomy and/or endotracheal intubation. Although Candida esophagitis is a recognized cause of similar symptoms, it is usually not suspected except in immunologically compromised hosts. This report describes the case histories of five patients, not immunosuppressed or cachectic, who developed persistent dysphagia during recovery from cardiac operations; four patients received only 4 days of preoperative and postoperative prophylactic antibiotic treatment with cefazolin (Kefzol) and cephalexin (Keflex). A nasogastric tube had been used for less than 24 hours in the postoperative period. The fifth patient developed symptoms following prolonged and varied antibiotic therapy. Candida esophagitis was diagnosed by a combination of coexisting oral candidiasis (5/5), roentgenographic appearance on barium swallow (5/5), endoscopy (4/4), and biopsy or culture (2/4). Initial therapy consisted of antireflux measures and antacids (4/5), cimetidine (4/5), oral nystatin in methylcellulose base (1,000,000 units every 4 hours) (4/5), and termination of other antibiotic therapy (1/5). These measures were effective in clearing the infection in only two patients. A third patient required prolonged massive oral nystatin therapy, and in two patients intravenous Amphotericin B was necessary to control infection. Two patients subsequently developed strictures which necessitated multiple esophageal dilatations. One of these patients developed endocarditis during home dilatation therapy. All patients are currently free of disease. Current measures utilized to recognize and treat the disease are discussed.

[Fungal infection after antibiotic therapy (author's transl)]

The increasing use of antibacterial chemotherapy in the last four decades encourages the commensal colonization of man by candida yeasts. The sites of particular commensal colonization are the oropharyngeal cavity and the intestinal tract. They are the principal reservoirs from which candida infections can settle into other regions and organs. The metastasis of candida yeasts from the commensal reservoir into regions which are free of microorganisms in healthy persons, usually needs a stimulant noxa: an eliciting bacterial infection, a consumptive primary disease, immunosuppressive therapy among other factors. In the event of candida infection being superimposed on a bacterial infection, successful antibacterial chemotherapy may lead to a remission of the mycosis by removal of the primary noxa.