Spontaneous fungal peritonitis: Epidemiology, current evidence and future prospective

Spontaneous bacterial peritonitis is a complication of ascitic patients with end-stage liver disease(ESLD); spontaneous fungal peritonitis(SFP) is a complication of ESLD less known and described. ESLD is associated to immunodepression and the resulting increased susceptibility to infections. Recent perspectives of the management of the critically ill patient with ESLD do not specify the rate of isolation of fungi in critically ill patients,not even the antifungals used for the prophylaxis,neither optimal treatment. We reviewed,in order to focus the epidemiology,characteristics,and,considering the high mortality rate of SFP,the use of optimal empirical antifungal therapy the current literature.

Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: A literature review

Spontaneous bacterial(SBP) and spontaneous fungal peritonitis(SFP) can be a life-threatening infection in patients with liver cirrhosis(LC) and ascites. One of the possible mechanisms of developing SBP is bacterial translocation. Although the number of polymorphonuclear cells in the culture of ascitic fluid is diagnostic for SBP, secondary bacterial peritonitis is necessary to exclude. The severity of underlying liver dysfunction is predictive of developing SBP; moreover, renal impairment and infections caused by multidrug-resistant(MDR) organism are associated with a fatal prognosis of SBP. SBP is treated by antimicrobials, but initial empirical treatment may not succeed because of the presence of MDR organisms, particularly in nosocomial infections. Antibiotic prophylaxis is recommended for patients with LC at a high risk of developing SBP, gastrointestinal bleeding, or a previous episode of SBP, but the increase in the risk of developing an infection caused by MDR organisms is a serious concern globally. Less is known about SFP in patients with LC, but the severity of underlying liver dysfunction may increase the hospital mortality. SFP mortality has been reported to be higher than that of SBP partially because the difficulty of early differentiation between SFP and SBP induces delayed antifungal therapy for SFP.

Spontaneous fungal peritonitis: Micro-organisms, management and mortality in liver cirrhosis-A systematic review

BACKGROUND Spontaneous peritonitis is an infection of ascitic fluid without a known intraabdominal source of infection. spontaneous fungal peritonitis (SFP) is a potentially fatal complication of decompensated cirrhosis, defined as fungal infection of ascitic fluid in the presence of ascitic neutrophil count of greater than 250 cells/mL. AIM To determine the prevalence of fungal pathogens, management and outcomes (mortality) of SFP in critically ill cirrhotic patients. METHODS Studies were identified using PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus databases until February 2019. Inclusion criteria included intervention trials and observation studies describing the association between SFP and cirrhosis. The primary outcome was in-hospital, 1-mo, and 6- mo mortality rates of SFP in cirrhotic patients. Secondary outcomes were fungal microorganisms identified and in hospital management by anti-fungal medications. The National Heart, Lung and Blood Institute quality assessment tools were used to assess internal validity and risk of bias for each included study. RESULTS Six observational studies were included in this systematic review. The overall quality of included studies was good. A meta-analysis of results could not be performed because of differences in reporting of outcomes and heterogeneity of the included studies. There were 82 patients with SFP described across all the included studies. Candida species, predominantly Candida albicans was the fungal pathogen in majority of the cases (48%-81.8%) followed by Candida krusei (15%- 25%) and Candida glabrata (6.66%-20%). Cryptococcus neoformans (53.3%) was the other major fungal pathogen. Antifungal therapy in SFP patients was utilized in 33.3% to 81.8% cases. The prevalence of in hospital mortality ranged from 33.3% to 100%, whereas 1-mo mortality ranged between 50% to 73.3%. CONCLUSION This systematic review suggests that SFP in end stage liver disease patient is associated with high mortality both in the hospital and at 1-mo, and that antifungal therapy is currently underutilized.

Risk factors, clinical features, and short-term prognosis of spontaneous fungal peritonitis in cirrhosis: A matched case-control study

BACKGROUND Spontaneous peritonitis is one of the most common infectious complications in cirrhotic patients with ascites.Spontaneous fungal peritonitis (SFP) is a type of spontaneous peritonitis that is a less recognized but devastating complication in end-stage cirrhosis.Although high mortality was previously noted,scant data are available to fully define the factors responsible for the occurrence of SFP and its mortality.AIM To illustrate the differences between SFP and spontaneous bacterial peritonitis (SBP) and discuss the risk factors for the occurrence of SFP and its short-term mortality.METHODS We performed a matched case-control study between January 1,2007 and December 30,2018.Patients with SFP were included in a case group.Sex-,age-,and time-matched patients with SBP were included in a control group and were further divided into control-1 group (positive bacterial culture) and control-2 group (negative bacterial culture).The clinical features and laboratory parameters,severity models,and prognosis were compared between the case and control groups.Logistic regression analysis was used to determine the risk factors for occurrence,and the Cox regression model was used to identify the predictive factors for short-term mortality of SFP.RESULTS Patients with SFP exhibited more severe systemic inflammation,higher ascites albumin and polymorphonuclear neutrophils,and a worsened 15-d mortality than patients in the control groups.Antibiotic administration (case vs control-1: OR = 1.063,95%CI: 1.012-1.115,P = 0.014;case vs control-2: OR = 1.054,95%CI: 1.014-1.095,P = 0.008) remarkably increased the occurrence of SFP or fungiascites.Hepatorenal syndrome (HR = 5.328,95%CI: 1.050-18.900) and total bilirubin (μmol/L;HR = 1.005,95%CI: 1.002-1.008) represented independent predictors of SFP-related early mortality.CONCLUSION Long-term antibiotic administration increases the incidence of SFP,and hepatorenal syndrome and total bilirubin are closely related to short-term mortality.

The Factors Related to Fungal Peritonitis in Patients on Peritoneal Dialysis

Fungal peritonitis (FP) is a serious infectious complication of peritoneal dialysis (PD). This retrospective study was conducted in 11 cases of FP a-mong 64 cases of patients with bacterial peritonitis (BP). Our results showed that age and sex underlying disease did not correlate significantly with the development of FP (P>0. 05),while long-term, repeated administration of antibiotics did (P<0. 01). It is suggested that the patients recently suffering from BP and being re-sistant to antibiotics were at great risk of suffering from FP. The key to preventFP was to avoid BP, to use sensitive antibiotics with appropriate courses and to give nutritive treatment.

Peritonitis due to <i>Geotrichum candidum</i>in Continuous Ambulatory Peritoneal Dialysis

This paper is a report of a 34-year-old man with chronic renal failure undergoing Continuous Ambulatory Peritoneal Dialysis which developed peritonitis due to Geotricum candidum. The diagnosis was established by culture of dialysis fluid. The purpose of this report is to provide data on a fungal peritonitis due to a non-common agent.

Peritoneal dialysis associated infections: An update on diagnosis and management

Peritoneal dialysis （PD） is associated with a high risk of infection of the peritoneum, subcutaneous tunnel and catheter exit site. Although quality standards demand an infection rate 〈 0.67 episodes/patient/year on dialy-sis, the reported overall rate of PD associated infection is 0.24-1.66 episodes/patient/year. It is estimated that for every 0.5-per-year increase in peritonitis rate, the risk of death increases by 4% and 18% of the episodes resulted in removal of the PD catheter and 3.5% re-sulted in death. Improved diagnosis, increased aware-ness of causative agents in addition to other measures will facilitate prompt management of PD associated infection and salvage of PD modality. The aims of this review are to determine the magnitude of the infection problem, identify possible risk factors and provide an update on the diagnosis and management of PD as-sociated infection. Gram-positive cocci such as Staphy-lococcus epidermidis , other coagulase negative staphy-lococcoci, and Staphylococcus aureus （S. aureus ） are the most frequent aetiological agents of PD-associated peritonitis worldwide. Empiric antibiotic therapy must cover both gram-positive and gram-negative organ-isms. However, use of systemic vancomycin and cip-rofoxacin administration for example, is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis - success rate of 77%. However, for fungal PD peritonitis, it is now standard practice to remove PD catheters in addition to antifungal treatment for a minimum of 3 wk and subsequent transfer to hemodi-alysis. To prevent PD associated infections, prophylactic antibiotic administration before catheter placement, adequate patient training, exit-site care, and treatment for S. aureus nasal carriage should be employed. Mupi-rocin treatment can reduce the risk of exit site infection by 46% but it cannot decrease the risk of peritonitis due to all organisms.

腹膜透析相关真菌性腹膜炎的危险因素及结局分析

目的探讨腹膜透析(PD)相关性真菌性腹膜炎(FP)的危险因素及结局。方法回顾性分析2017年1月至2022年12月19例FP患者的临床资料,按1:5抽取同期诊断为细菌性腹膜炎的95例患者为对照组,分析FP的结局及其危险因素。结果19例FP中共检出真菌22株,包括白假丝酵母菌7株,光滑念珠菌5株,近平滑念珠菌4株,热带念珠菌2株,无名念珠菌1例,弯孢菌1株,黄曲霉菌1株,罗伦特隐球菌1株。与对照组比较,FP组既往抗生素使用率(P<0.001)和腹膜炎发生率(P=0.015)更高,腹透时间(P=0.012)更长,血清白蛋白(Alb)更低(P=0.006),高敏C-反应蛋白(HsCRP)(P=0.034)水平更高。转血透率(P<0.001)和自动出院率(P=0.023)更高。Logistic回归分析显示,既往有腹膜炎病史、1个月内使用抗生素、腹透时间长是FP的危险因素。Kaplan-Meier生存曲线分析显示两组生存率差异无统计学意义(P>0.05)。结论既往使用抗生素、PDAP病史、长透析龄是FP的危险因素。FP是腹膜透析的严重并发症,是导致腹透患者转血透和3个月内死亡的主要原因,应警惕过度抗生素的使用,确诊后尽早抗真菌治疗及拔管。

青霉菌导致腹膜透析相关性腹膜炎1例并文献复习

腹膜透析相关性腹膜炎是腹膜透析治疗的严重并发症,可导致多种不良临床结局。因此,预防及治疗腹膜透析相关性腹膜炎是改善患者预后的重要环节。临床上大多数腹膜透析相关性腹膜炎是由革兰氏阳性球菌引起的,青霉菌属较为罕见。本文报道1例45岁女性腹膜透析相关性腹膜炎患者,既往行电子结肠镜检查提示结直肠炎。入院后先后使用左氧氟沙星、亚胺培南西司他丁、氟康唑等抗感染治疗,后续腹膜透析管微生物培养结果提示青霉菌感染,予拔除腹膜透析管并使用伏立康唑抗真菌治疗后腹膜炎治愈。本例患者在诊治过程中发现其临床表现及常规实验室检查无特异性,对于治疗效果不佳或病原体培养阴性的腹膜炎患者,需警惕青霉菌感染的可能。在及时、规范治疗腹膜炎的同时应注意识别并处理腹膜透析相关性腹膜炎的易感因素。

制霉菌素对腹膜透析霉菌性腹膜炎的预防作用

目的:研究持续性非卧床腹膜透析（CAPD）细菌性腹膜炎（BP）在用抗菌素治疗同时应用制霉菌素对霉菌性腹膜炎（FP）发生的预防作用。方法:回顾性研究了1995年6月至2000年11月期间预防组应用制霉菌素（50万单位tid）预防治疗共有细菌性腹膜炎535例次/9970病人月,同期霉菌性腹膜炎37例次,其中原发性霉菌性腹膜炎21例次、继发性霉菌性腹膜炎13例次、复发性霉菌性腹膜炎3例次;未预防组细菌性腹膜炎58例次/969病人月,同期霉菌性腹膜炎7例次,其中原发性1例次、继发性6例次。糖尿病病人16例,4例发生霉菌性腹膜炎;非糖尿病73例,发生3例。结果:未预防组BP的发病率与预防组BP的发病率无明显差别P>0.05。未预防组霉菌性腹膜炎的发病率与预防组霉菌性腹膜炎的发病率无明显差别（P>0.05）。未预防组继发性霉菌性腹膜炎的发病率明显高于预防组P<0.05。未预防组糖尿病与非糖尿病比较糖尿病病人霉菌性腹膜炎发病率高（P<0.05）。结论:细菌性腹膜炎抗菌素的应用是霉菌性腹膜炎发生的危险因素,治疗细菌性腹膜炎的同时应用制霉菌素对霉菌性腹膜炎有预防作用。糖尿病患者较非糖尿病患者易患霉菌性腹膜炎,应积极预防。

皮炎外瓶霉导致的真菌性腹膜炎1例

报道1例由皮炎外瓶霉(Exophiala dermatitidis,Ed)导致的真菌性腹膜炎。此菌分离于1名长期腹膜透析患者的腹水。皮炎外瓶霉主要引起皮肤及皮下组织、中枢神经系统感染,引起腹膜炎者少见。现对此临床分离株进行真菌学分析、鉴定、药敏实验。患者经拔除透析管,改血液透析,同时抗真菌治疗,口服伊曲康唑0.2g/d,症状明显改善。

腹膜透析相关性真菌性腹膜炎易感因素及预后分析

目的探讨腹透相关性真菌性腹膜炎(FP)易感因素及预后。方法回顾性分析20例次FP临床资料,与同期收治的腹透相关性细菌性腹膜炎(BP)比较,分析FP的易感因素及预后。结果腹透相关性腹膜炎共400例次,FP占5.0%;FP组血红蛋白低于BP组;FP组中,45%患者近1个月内有腹腔或全身使用抗菌药物史,高于BP组(15%)。20例次FP中1例治愈,15例拔管,4例自动出院。FP组腹膜透析退出率及患者病死率均明显高于BP组。结论严重贫血,腹腔或全身使用抗菌药物是FP发生的高危因素,FP预后不良,尽早拔管可能降低病死率。

维持性腹膜透析患者并发真菌性腹膜炎23例临床分析

目的对维持性腹膜透析患者并发真菌性腹膜炎的临床资料进行回顾性分析,以提高对真菌性腹膜炎的治疗水平。方法选择2005年1月～2010年12月在我院住院并诊断为真菌性腹膜炎的腹膜透析患者,记录并分析所有患者的一般资料、病史、临床症状、治疗方法及转归。结果维持性腹膜透析患者并发真菌性腹膜炎(FP)者23例,糖尿病状态3例(13.0%)。FP发生前4周使用抗生素者19例(83.6%),使用免疫抑制剂1例(4.3%),9例(39.1%)患者因疼痛剧烈使用了镇痛剂。透析液培养结果为白色念珠菌18例(78%)。4例保管抗真菌治疗并继续腹膜透析,治愈2例;20例(87%)拔管改作血液透析;死亡2例(8.7%)。结论对真菌性腹膜炎提倡立即拔管,但在特殊情况下可予以适当考虑保留腹膜透析管。本研究为单中心回顾性研究,需设计更好的前瞻性研究探讨维持性腹膜透析患者并发真菌性腹膜炎的治疗细节。

延迟拔管的腹膜透析相关性腹膜炎的病原学特点

目的:探讨延迟拔管的腹膜透析相关性腹膜炎(PDAP)的病原学特点。方法:选取延迟拔管的PDAP患者共50例为研究对象(D组),以非难治性PDAP组(B组,n=37例)和难治性PDAP内科保守治疗有效组(C组,n=15例)为对照,进行腹膜透出液细菌、真菌培养。结果:腹膜炎总的培养阳性率为74.5%,其中B、C、D三组培养阳性率分别为81.1%、46.7%、78.0%。与B组比,D组真菌感染、二重感染比例均为23.1%,明显升高(P<0.01)。与B、C组比,D组真菌+二重感染+混合感染比例高达56.4%,明显升高(P<0.01)。D组32例(64.0%)进行动态培养,其中18例病原菌转为阴性,6例G^+或G^-菌转为混合感染、2例真菌菌种不断变化,2例G^+球菌持续阳性,4例病原菌持续阴性。经治疗90 d死亡7例、存活率86.0%。结论:延迟拔管的PDAP病原学以真菌+二重感染+混合感染为主。动态监测病原菌的演变,有助于指导治疗及提高疗效。

棕黑腐质霉(Humicola fuscoatra)导致真菌性腹膜炎1例

报道1例由棕黑腐质霉属(Humicola fuscoatra)导致的真菌性腹膜炎。此菌分离自1名长期腹膜透析患者的腹水。腐质霉属在自然界广泛存在,棕黑腐质霉导致的人类感染罕见。现对棕黑腐质霉的真菌学特点进行研究,并进行分子测序。体外药物敏感性试验结果对伊曲康唑的MIC为0.008μg/mL,伏立康唑的MIC为0.016μg/mL,两性霉素B的MIC为1.5μg/mL。患者拔除腹透管,改行血液透析。口服伊曲康唑0.1 g/12 h,28 d后病情明显改善,出院。

大鼠真菌性腹腔炎症渗出液的上清液抗白色念珠菌作用研究

目的:观察大鼠真菌性腹腔炎症渗出液和其成分对白色念珠菌的杀菌作用,为开发天然抗真菌的药物提供信息。方法:给大鼠腹腔注射活的白色念珠菌造成真菌感染模型,观察腹腔炎症渗出液的上清液对白色念珠菌的杀菌作用。结果:造模后24 h腹腔炎症渗出液的量最多,渗出液上清液对白色念珠菌具有强的杀菌作用,20%上清液的杀菌率达(87.00±4.10)%;经56℃水浴10 min后,80%上清液的杀菌率从99.8%下降到9.1%。结论:大鼠真菌性腹腔炎症渗出液上清液中存在强的抗真菌物质,可能是一种或多种抗真菌蛋白/多肽。

腹膜透析相关性丝状真菌腹膜炎拔管后重置1例并文献复习

目的报道腹膜透析相关性丝状真菌腹膜炎1例的诊疗过程及其预后,并结合文献复习以加强对该病诊疗方面的认识。方法回顾性分析解放军第117医院收治的1例腹膜透析相关丝状真菌腹膜炎患者资料,并总结复习相关文献。结果持续性不卧床腹膜透析的女性糖尿病患者,在出现腹膜透析相关性腹膜炎症状后,给予头孢他啶联合头孢唑林抗感染治疗15d,症状无明显改善;随后腹膜透析液培养提示丝状真菌,立即停用抗生素,给予氟康唑抗真菌治疗,并行腹膜透析管拔管术,术中腹膜透析管内奶酪样物质送检培养提示丝状真菌生长。患者拔管后行血液透析治疗,半年后重置腹膜透析管,行腹膜透析治疗,1.5%腹膜透析液4次/日;2周后测尿量650 ml,超滤量-490 ml,残肾尿素清除指数(Kt/V)0.811,腹膜Kt/V 1.832,总Kt/V 2.64/周,残肾内生肌酐清除率(endogenous creatinine clearance rate,Ccr)35.7,腹膜Ccr 38.9,总Ccr 74.6/周,氮表现率蛋白相当量1.12,提示透析充分,营养状况良好,PET试验提示高平均转运型。连续随访3年患者腹膜透析充分,后因无菌操作不规范致反复细菌性腹膜炎,最终诊断为腹膜超滤衰竭,退出腹膜透析,改行血液透析至今。结论目前腹膜透析相关丝状真菌性腹膜炎治疗以拔管后退出腹膜透析为主,而在腹膜炎治愈、一般情况良好的条件下,仍可以考虑腹膜透析管重置。

毛霉菌致持续性非卧床腹膜透析患者腹膜炎的临床分析

目的分析持续性非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)患者感染毛霉菌性腹膜炎的临床特点。方法分析临床诊断毛霉菌性腹膜炎的CAPD患者1例并进行系统文献复习。结果男性患者73岁,有腹痛及持续性发热症状,体检脐周有压痛,腹透液检查示中性粒细胞升高,腹透液培养出须藓毛藓菌。大扶康治疗效果欠佳,后经卡泊芬静、终止腹膜透析、改为血液透析等治疗后患者体温恢复正常,腹痛消失。结论毛霉菌性腹膜炎与其他霉菌性腹膜炎临床表现相似,诊断及鉴别诊断易混淆;拔除腹透管是CAPD患者霉菌性腹膜炎好转的必要条件。

1,3-β-D葡聚糖检测对上消化道穿孔继发腹腔真菌感染早期诊断的意义

目的探讨1,3-β-D葡聚糖(1,3-β-D Glucan BG)检测对上消化道穿孔继发腹腔真菌感染早期诊断的意义。方法以14例上消化道穿孔术后继发腹腔真菌感染患者为观察组,以16例上消化道穿孔术后未发生腹腔真菌感染患者为对照组,于术后第1、3、5、7天定量检测血浆以及腹腔液BG的含量。结果观察组第3、5、7天血浆及腹腔引流液BG明显高于对照组,且差异具有显著统计学差异。结论上消化道穿孔患者中,血浆和腹腔引流液BG含量检测对腹腔真菌感染的早期诊断具有指导意义。

5例腹膜透析相关的真菌性腹膜炎临床分析

目的探讨腹膜透析患者真菌感染的发生率、致病真菌以及感染的主要因素及处理结果。方法回顾性分析58例腹膜透析患者的临床资料,对真菌感染患者从临床症状、真菌学检查、治疗及预后进行详细的论述,探讨腹膜透析与真菌感染的关系。结果腹膜透析治疗的58例患者中有5例发生真菌性腹膜炎,感染率为8.6%,致病菌4例为白念珠菌,1例为近平滑念珠菌,其中4例患者经抗真菌和拔出腹透管处理,治疗效果较为理想。1例患者因病情危重伴有其他细菌感染,最终死于其他并发症。结论真菌感染是腹膜透析患者较严重的并发症,尽管发生率不高,但如果不及时处理后果严重,早诊断、早治疗并根据实际情况考虑拔除腹透管尤为重要。