PCR-detected fungal infection is associated with fatal outcomes in cirrhotic patients with spontaneous peritonitis

Abstract

Background & aims: The rate of mortality from Spontaneous Peritonitis (SP) in cirrhotic patients is still high despite the development of new antibiotic treatments and intensive hospital care. The coexistence of spontaneous fungal peritonitis (SFP) is almost entirely ignored health problem, because it is difficult to be diagnosed at an early stage by conventional culture-based methods. Therefore, this study was designed to employ PCR-based method in evaluating the prevalence of fungal infection in cirrhotic patients with peritonitis who failed to respond to the recommended therapy and to determine its association with in-hospital mortality. Subjects and Methods: A total of 80 cirrhotic patients admitted to the hospital with ascitis (June-2013 to April-2015) were followed in this study. Results: During hospitalization, 23 (42%) of patients had died although they received guideline-driven treatment. The demographics, clinical, hematological, and biochemical data were similar in both mortality and survival groups. However, the incidence of fungus infection was the only significantly elevated parameter in the mortality group than in the survival group (7/23;30% vs.0/32;0%, P = 0.0012). This fungal infection was significantly associated with SP drug resistance development (P = 0.007). Intriguingly, all the cases of fungal infection were detected by PCR-based method while culture-based diagnosis was able to detect the fungal infection in only 4 of these cases indicating a diagnostic sensitivity of 57%. Conclusion: Our results reflect a strong association between SFP and in-hospital mortality in cirrhotic patients with SP that may offer a coherent explanation for the antibiotic treatment failure in such patients. Prompt PCR-detection and antifungal coverage is warranted in these cases.

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

“…[ 154 ]. Polymicrobial infections, i.e., bacterial co-colonization, occurs in 32%-74% of SFP cases[ 148 , 149 , 153 , 154 , 156 ], but early diagnosis by conventional microbial culture is difficult because of the time required for growth[ 155 ], and the efficacy of PCR or assay of the fungal biomarker 1,3-beta- D -glucan in ascitic fluid has not been established[ 149 , 155 ].…”

“…Risk factors associated with hospital mortality in SFP include severe underlying liver disease[ 148 ], Child-Pugh score[ 155 ], MELD score[ 149 ], antibacterial prophylaxis[ 6 ], incidence of HRS[ 6 ], low ascites protein concentration[ 6 ], Acute Physiology And Chronic Health Evaluation II score[ 149 ], and sepsis shock[ 153 ]. SFP mortality is estimated to be 56%-90%[ 5 , 148 , 149 , 151 , 153 ], and 1-mo mortality may[ 148 , 153 ] or may not be significantly higher than SBP mortality[ 149 , 157 ].…”

“…SFP is usually diagnosed after the identification of fungi in cultures of ascitic fluid. The mortality is high because of delayed diagnosis, lack of clinical signs, lack of suspicion of SFP, and delay in treatment with antifungal therapy[ 5 , 6 , 148 , 155 , 156 , 158 ]. Fungal resistance to empirical specific antifungal therapy together with delayed diagnosis and treatment is related to poor prognosis of SFP[ 153 ].…”

Spontaneous Fungal Peritonitis in Patients with Liver Cirrhosis

“…Early diagnosis of SFP and fungiascites is challenging, partly because of the time required for diagnostic fungal cultures [14] and partly because of lack of suspicion of SFP or fungiascites by the clinician. Diagnostic methods for SFP or fungiascites include polymerase chain reaction (PCR), 1,3-beta-D-glucan assay and galactomannan of the ascitic fluid [9,[14][15][16][17][18].…”

“…Although the clinical characteristics and prognosis of SBP have been well documented [5], the clinical characteristics of SFP and fungiascites in patients with LC are less well known. However, some clinical studies of SFP and fungiascites have been reported in recent years, including those that have evaluated and compared SFP and SBP [6][7][8][9][10] or spontaneous peritonitis with a funguspositive ascitic culture (SFP or fungiascites) and spontaneous peritonitis with a bacteria-positive ascitic culture (culture-positive SBP or bacterascites) [11,12]. In the present article, we review and summarize spontaneous peritonitis due to fungal infections (SFP and fungiascites).…”