Fungal Peritonitis: Underestimated Disease in Critically Ill Patients with Liver Cirrhosis and Spontaneous Peritonitis

Abstract

IntroductionSpontaneous peritonitis, especially spontaneous fungal peritonitis (SFP), is an important and potentially fatal complication in patients with endstage liver disaese. We evaluated potential risk factors, microbiological findings, and outcome of patients with SFP compared to spontaneous bacterial peritonitis (SBP) in critically ill patients.MethodsRetrospective analyses of critically ill patients with suspected spontaneous peritonitis.ResultsOut of 205 patients, 20 (10%) had SFP, 28 (14%) had SBP, 48 (24%) had peritonitis without microbiological findings (SP) and 109 (52%) had no-peritonitis (NP). APACHE II and SOFA score were significantly higher in patients with SFP (26; 22–28; p<0.004 and 16; 14–18; p<0.002), SBP (26; 22–28; p<0.004 and 16; 14–18; p<0.002) and SP (24; 18–30; p<0.045 and 14; 10–18; p<0.044) as compared to NP (22; 16–24 and 12; 10–14). CHILD Pugh classification was mainly CHILD C and MELD Score was in patients with SFP (34; 18–40; p<0.001), SBP (32;12–40 p<0.002) and SP (29; 14–40 p<0.003) significantly higher as compared to NP (25;8–40). Nosocomial peritonitis could be significantly more often found in patients with SFP (65%; p<0.023) and SBP (62%, p<0.030) as compared to SP (51 p = 0.243) and NP (45%). Antibiotic pretreatment last 3 month prior peritonitis was significantly more often in patients with SFP (85%; p<0.002), SBP (71%, p<0.033), and SP (56; p<0.040) as compared to NP (33%). Candida albicans (60%; 12/20) was the most common isolated fungus, followed by Candida glabrata (13%) and Candida krusei (13%). Mortality rate was significantly higher in patients with SFP (90%, p<0.001), followed by SBP (75%; p<0.001) and SP (69%; p<0.001) as compared to NP (45%).ConclusionSFP is not a rare complication in end stage liver disease which is associated with increased mortality. Physicians should be aware of SFP in patients with CHILD C liver cirrhosis, elevated MELD score, antibiotic pretreatment and nosocomial peritonitis.

Invasive fungal infections amongst patients with acute‐on‐chronic liver failure at high risk for fungal infections

“…Invasive candidiasis was the dominant (64%) IFI followed by the invasive aspergillosis (36%) in patients with ACLF. Others have reported the similar spectrum of fungal infections in cirrhosis . This is likely because of fungal dysbiosis and breach in gut mucosal barrier in advanced cirrhosis and hence the transmucosal migration of commensal Candida or superinfection because of Aspergillus species …”

“…Recently, Bajaj et al reported IFI in 5% cirrhotics (of which 43% had ACLF). Others have reported a variable occurrence of fungal infections in patients with cirrhosis (1%‐66%) . The variability was because of lack of a uniform diagnostic criteria, confounding because of fungal colonization, delayed diagnosis owing to use of conventional diagnostics only in addition to heterogeneous aetiologies and variable severity of liver dysfunction in different studies.…”

Treatment of Patients with Cirrhosis

“…is the most common fungus isolated [4][5][6]. SFP mortality is very high ranging from 90% to 100% of patients [4,5]. Hospitalization seems to be a SFP risk factor [4,5].…”

“…SFP mortality is very high ranging from 90% to 100% of patients [4,5]. Hospitalization seems to be a SFP risk factor [4,5]. In a randomized controlled trial, an antifungal agent was added in hospital-acquired SBP with no response to broad-spectrum antibacterial agents: the results of this study showed that addon of an antifungal agent are more effective than antibacterial alone as empirical antimicrobial treatment of SBP [7].…”

“…SFP prevalence varies from 3.6% to 41% of patients with a positive ascitic fluid culture; Candida spp. is the most common fungus isolated [4][5][6]. SFP mortality is very high ranging from 90% to 100% of patients [4,5].…”