Fungal peritonitis in continuous ambulatory peritoneal dialysis: The impact of antifungal prophylaxis on patient and technique outcomes

Abstract

Fungal peritonitis (FP) is a rare, but serious complication of peritoneal dialysis. We analyzed the incidence of FP, associated risk factors and outcome of patients with FP and evaluated the role of prophylactic antifungal agent in reducing its incidence. We studied all patients with FP from January 2005 to January 2012. Study period was divided into two parts, period I (January 2005 to January 2010), when prophylactic antifungal was not used and period II (January 2010 to January 2012), when prophylactic antifungal (fluconazole) was used. A total of 142 episodes of peritonitis were documented during this period of which 20 (14%) were FP. During the study period I, 18 of 102 episodes of peritonitis (17.6%) and in the study period II (with antifungal prophylaxis), only 2 of 40 episodes of peritonitis (5%) were due to fungal infection (P = 0.04). Nine out of 20 patients (45%) had prior exposure to antibiotics. Fungal isolates were Candida albicans in 65%, non-albicans Candida in 25%, Rhizopus species in 5% and Alternaria in 5% of the patients. While 12 out of 20 patients (60%) recovered completely and were re-initiated on continuous ambulatory peritoneal dialysis (CAPD), 4 of them expired (20%) and 4 others (20%) were shifted to hemodialysis. Use of prophylactic antifungal agent significantly reduced the incidence of FP (P = 0.04). We conclude that - fluconazole when used as a prophylactic agent in the setting of bacterial peritonitis significantly reduces the incidence of subsequent FP in CAPD patients.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

“…Unfortunately, nystatin is not available in some countries. Observational data 118 –120 and one randomised controlled trial 122 showed that prophylactic fluconazole is effective. The randomised controlled trial of oral fluconazole included patients who received antibiotics for treating exit-site and tunnel infection, in addition to the treatment of peritonitis 122 .…”

“…The majority of fungal peritonitis episodes are preceded by courses of antibiotics. [109][110][111][112] A number of observational studies [113][114][115][116][117][118][119][120] and randomised trials 121,122 have examined the use of either oral nystatin (500,000 units qid) or fluconazole (200 mg every 48 h) as prophylaxis during antibiotic therapy. In essence, two randomised control trials 121,122 and a systematic review 43 showed a significant benefit.…”

ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment

“…Unfortunately, nystatin is not available in some countries. Observational data and 1 randomized controlled trial showed that prophylactic fluconazole is effective ( 197 – 200 ). However, there are potential problems (e.g.…”

Peritonitis by Exophiala dermatitidis in a pediatric patient

“…The association of fungal infection to this procedure have been shown repeatedly in the literature on peritonitis in adult [7,[20], [21], [22]] and children [23], mostly caused by Candida species. Fungi commonly are involved in biofilm formation on indwelling and prosthetic materials, interfering with eradication the infection [22]. Therefore, after final diagnosis the catheter as likely source of infection was removed.…”