Spontaneous bacterial peritonitis is a well-known complication of cirrhosis; however, spontaneous fungal peritonitis (SFP) is less well-recognised and described. Our objective was to determine the clinical characteristics, treatment outcomes and factors associated with death among patients with SFP. We performed a retrospective cohort study using the primary outcome of all-cause mortality at 28 days. Twenty-five patients were included; Candida species were the causative pathogen in all cases. At the onset of SFP, patients were critically ill, median APACHE II and MELD scores were 22 and 30.3, respectively. The 28-day mortality rate was 56%; six patients died prior to culture positivity. Among the remaining patients, there were no differences in rates of death by treatment regimen (P = 0.55). APACHE II score at the onset of SFP was an independent predictor of death (OR = 1.46, 95% CI = 1.02-2.08, P = 0.04). In conclusion, SFP develops among critically ill patients with cirrhosis and is associated with high rates of death. Directed antifungal therapy did not improve patient outcomes. Future studies assessing the benefit of early or pre-emptive antifungal therapy are warranted.

The use of IV vitamin K to correct coagulopathy of cirrhosis may not be beneficial.

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Background: Vitamin K antagonists (eg, warfarin) remain the mainstay of anticoagulation therapy in the United States, with over 22 million prescriptions being filled annually. Unfortunately, warfarin therapy is difficult to manage and increases bleeding risk. The 2012 American College of Chest Physicians guidelines created a warfarin reversal algorithm that suggested the stringent use of intravenous vitamin K. Objective: The purpose of this evaluation was to determine the rates of adherence with guideline recommendations in clinical practice. Method: A convenience sample of 3 months of intravenous vitamin K medication administration data (September to November 2013) was obtained to conduct a retrospective review. Patients with underlying hepatic dysfunction or lack of warfarin therapy were excluded. Vitamin K use was evaluated for consistency with the 2012 guidelines. Results: A total of 364 patients were reviewed and 119 were included. Vitamin K utilization was consistent with guideline recommendations for a total of 30 (25.2%) patients. The most common site of active bleeding requiring reversal was head bleeds, consisting of 56.6% of bleeds. A single dose of 10 mg of vitamin K was the most frequently used dosing strategy. Fresh frozen plasma (73.3%) and four-factor prothrombin complex concentrate (36.7%) were the most commonly used factor products. Conclusion: This evaluation demonstrates that there is a difference between clinical judgment and guideline adherence. True adherence with the guidelines may not be necessary; however, there is room for improvement in both the appropriateness and safety of intravenous vitamin K use. 1 The volume of prescriptions is most likely driven by the familiarity with the long-standing product, comfort with the approach to reversal, and the wide array of US Food and Drug Administration (FDA)-approved indications, including cardiac valve replacement, prevention and/or treatment of venous thromboembolism, and prevention and/or treatment of thromboembolic complications associated with atrial fibrillation. Vitamin K antagonists achieve their anticoagulant effects through the inhibition of vitamin K epoxide reductase (VKOR). For most indications, warfarin is dosed to achieve an international normalized ratio (INR) of 2.0 to 3.0. Key2 When the INR drops below 2.0, patients are considered to be subtherapeutic and at a higher risk for thrombotic complications; Bleeding events while on warfarin are common, with an annual bleeding event rate between 1.7% and 3.4% in the United States.6 Hemorrhagic complications are responsible for more than 60,000 annual emergency department visits in VKA-treated patients.7 Of all VKA-treated patients, between 3% and 7% will require rapid reversal for either VKAassociated major bleed or for an emergent surgical procedure. 8 The administration of vitamin K (phytonadione) has the ability to overcome the inhibition of VKOR and reverse anticoagulation. Although there are other therapies to correct excessive anticoagulation such as fresh frozen plasm...

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