Clinical Outcomes of Intra‐Abdominal Candidiasis by Initial Antifungal Therapy

BACKGROUND: Intra-abdominal candidiasis (IAC) is a severe and heterogeneous infection associated with significant morbidity and mortality. OBJECTIVES: To evaluate outcomes of IAC according to initial antifungal therapy and to identify predictors of persistent infection and 30-day mortality. METHODS: A retrospective non-randomised single-centre study (January 2020-February 2025) evaluated adult IAC according to the initial antifungal (azoles vs. echinocandins), assessing demographics, type, location, and persistent positive cultures, re-intervention, antifungal reintroduction, and 3- and 90-day mortality. Multivariate logistic regression identified predictors of persistent cultures and 30-day mortality, and inverse probability of treatment weighting (IPTW) addressed confounding in mortality analyses. RESULTS: Among 154 patients (median age 64.5 years, 66.9% male), 102 received azoles and 52 echinocandins, with greater severity in the latter group. Persistent positive cultures occurred in 51.7% (46/89), without difference between groups. Factors associated with persistent positive cultures included concomitant candidemia, septic shock, previous antibiotic usage, and peritonitis. The 30-day mortality was 28.1% (higher with echinocandins, 38.5% vs. 22.8% in azole group, p = 0.041). Multivariate logistic regression and IPTW indicated that the initial antifungal therapy did not affect 30-day mortality, while septic shock (OR:2.2, 95% CI:1.0-4.9; p = 0.047) and age ≥ 60 years (OR:2.6, 95% CI:1.1-6.3; p = 0.032) were significantly associated with it. CONCLUSIONS: IAC remains a complex infection with substantial morbidity and mortality. Echinocandins are preferred in critically ill patients, but mortality did not differ significantly between initial echinocandin and azole treatment. Persistent positive cultures were linked to severe presentation, including peritonitis, candidemia, and septic shock, which required more frequent re-intervention, and consequently carried higher mortality.