Intra-abdominal Yeast Infections: A Single-Center Experience in Cairo, Egypt
Objective:
	In the past few years, intra-abdominal yeast infections have been reported with increasing frequency and significant morbimortality rates. However, the actual incidence of these infections remains under studied.
	The present study aims to shed light on the prevalence of the disease in Egypt, and investigate the predisposing factors, the clinical characteristics, microbiology and suggest the most effective antifungal agents against the recovered isolates.
Methods:
	A total of 100 patients from Ain Shams University Hospitals (Cairo, Egypt) diagnosed with intra-abdominal infection during the period from January 2016 to September 2017 were included in this study.
	An episode of intra-abdominal yeast infection was defined by clinical evidence of intra-abdominal infection and isolation of yeast from an intra-abdominal sample collected under aseptic condition. Demographic, microbiologic and clinical data were collected from hospital medical records.
	Yeast isolates were identified to species level using Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry analysis (MALDI-TOF MS) (VITEK® MS, bioMérieux Inc., Marcy l'Etoile, France) and their antifungal susceptibility against fluconazole, voriconazole, caspofungin, micafungin, amphotericin B and flucytosine was tested using the Vitek2 system (bioMérieux Inc., Marcy l'Etoile, France). 
Results:
	From the 100 patients included in this study, 17 cases (17%) were identified as intra-abdominal yeast infections. Intra-abdominal infections caused by filamentous fungi and bacteria represented 26 cases (26 %) and 57 cases (57%) respectively.
	The median age of the patients was 51 (range 42-61 years) of which 94.1% were male and 5.9% were female. The predisposing factors for intra-abdominal yeast infections were liver and kidney transplantation (58.8% and 23.5% respectively), peritoneal dialysis (5.9%), appendectomy (5.9%) and HIV infection (5.9%).
	Secondary peritonitis was the most predominant type of intra-abdominal yeast infections (64.7%), followed by cholecystitis/cholangitis (29.4%) and liver abscess (5.9%).
	Candida parapsilosis was the most prevalent species (47%) followed by C. guilliermondii (29.4%). C. tropicalis, C. glabrata, C. lipolytica and Trichosporon asahii were also recorded by one case each (5.9%).
	C. parapsilosis, C. tropicalis and C. lipolytica were susceptible to all the tested antifungals. Resistance to amphotericin B was reported among C. guilliermondii isolates. C. glabrata showed resistance to both voriconazole and fluconazole. Trichosporon asahii was susceptible to all antifungals except for caspofungin and micafungin.
	All the cases received micafungin for treatment within 5 days. Only one case shifted from micafungin to voriconazole. The median duration of treatment was 14 days (range 3 – 41 days). The overall mortality rate was 35.3%.

Conclusion: 
	This is the first report discussing the prevalence of intra-abdominal yeast infections in Egypt. The present study shows a shift toward non-albicans yeast infections with emerging resistance toward conventional antifungals and high mortality rates.
	Further studies are required to identify the risk factors for these infections and the rates of incidence among each risk group. Animal models are also required for better understanding of the infection and the appropriate antifungal treatment in the absence of clinical trials.