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

Abstract

BACKGROUND Spontaneous peritonitis is an infection of ascitic fluid without a known intra-abdominal 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.

Spontaneous Fungal Peritonitis in Patients with Liver Cirrhosis

“…Recent review article supports the usefulness of testing ascitic fluid using methods such as pan-fungal PCR and 1,3-beta-D-glucan assay for early diagnosis of SFP [19]. Therefore, these tests may also be performed at the first paracentesis in cases of suspected spontaneous peritonitis.…”

“…The breakdown of the intestinal mucosa barrier, dysbiosis (changes in the composition of the intestinal bacterial flora), translocation of pathogens, in addition to deficiencies in local host immune defenses may be involved in the onset of ascitic infections that reach the systemic circulation from the gut in patients with LC [23][24][25]. Fungi in the ascitic fluid in SFP or fungiascites may also be the result of a fundamental pathogenic mechanism of fungal translocation from the gut to systemic circulation [5,19]. Antibiotic treatment of SBP may increase the risk of fungal peritonitis by allowing excessive fungal growth in the intestinal flora [19].…”

“…Fungi in the ascitic fluid in SFP or fungiascites may also be the result of a fundamental pathogenic mechanism of fungal translocation from the gut to systemic circulation [5,19]. Antibiotic treatment of SBP may increase the risk of fungal peritonitis by allowing excessive fungal growth in the intestinal flora [19]. Subsequent translocation of fungi into the peritoneal cavity could induce SFP or fungiascites [19,26], even though their size may make fungal translocation across the gut mucosa more difficult than bacterial translocation [10,14,19].…”

“…Antibiotic treatment of SBP may increase the risk of fungal peritonitis by allowing excessive fungal growth in the intestinal flora [19]. Subsequent translocation of fungi into the peritoneal cavity could induce SFP or fungiascites [19,26], even though their size may make fungal translocation across the gut mucosa more difficult than bacterial translocation [10,14,19]. Fungal translocation may be facilitated by upper gastrointestinal bleeding, which is also common in patients with advanced LC [21].…”

“…Fungal translocation may be facilitated by upper gastrointestinal bleeding, which is also common in patients with advanced LC [21]. Direct percutaneous inoculation of fungi has been proposed as a route of fungal infection in patients with refractory ascites and a history of paracentesis [19,21]. Bajaj et al [3] reported that 6.0% (8/134) of fungal infections in patients with LC involved spontaneous peritonitis.…”