Abstract
BackgroundFungal peritonitis is a serious complication of peritoneal dialysis (PD) therapy with the majority of patients ceasing PD permanently. The aims of this study were to identify risk factors and clinical associations that may discriminate between fungal from bacterial peritonitis.MethodsWe retrospectively identified episodes of fungal peritonitis from 2001–2010 in PD patients at Liverpool and Westmead Hospitals (Australia). Fungal peritonitis cases were matched in a 1∶2 ratio with patients with bacterial peritonitis from each institution's dialysis registry, occurring closest in time to the fungal episode. Patient demographic, clinical and outcome data were obtained from the medical records.ResultsThirty-nine episodes of fungal peritonitis (rate of 0.02 episodes per patient-year of dialysis) were matched with 78 episodes of bacterial peritonitis. Candida species were the commonest pathogens (35/39; 90% episodes) with Candida albicans (37%), Candida parapsilosis (32%) and Candida glabrata (13%) the most frequently isolated species. Compared to bacterial peritonitis, fungal peritonitis patients had received PD for significantly longer (1133 vs. 775 catheter-days; p = 0.016), were more likely to have had previous episodes of bacterial peritonitis (51% vs. 10%; p = 0.01), and to have received prior antibacterial therapy (51% vs. 10%; p = 0.01). Patients with fungal peritonitis were less likely to have fever and abdominal pain on presentation, but had higher rates of PD catheter removal (79% vs. 22%; p<0.005), and permanent transfer to haemodialysis (87% vs. 24%; p<0.005). Hospital length of stay was significantly longer in patients with fungal peritonitis (26.1 days vs. 12.6 days; p = 0.017), but the all-cause 30-day mortality rate was similar in both groups. Fluconazole was a suitable empiric antifungal agent; with no Candida resistance detected.ConclusionPrompt recognition of clinical risk factors, initiation of antifungal therapy and removal of PD catheters are key considerations in optimising outcomes.
Highlights
Patients with end stage kidney disease (ESKD) undergoing dialysis are at increased risk of infections, with infection-related hospitalisation rates 31–68% higher than patients without kidney disease [1]
Uncommon compared with bacterial peritonitis, fungal peritonitis is associated with higher mortality rates (5%–53% vs. 0.7%–15%) [4,7] and often results in permanent discontinuation of peritoneal dialysis (PD) with high morbidity [4,8]
A total of 1568 PD peritonitis episodes occurred in 2075 patients over the 9-year study period
Summary
Patients with end stage kidney disease (ESKD) undergoing dialysis are at increased risk of infections, with infection-related hospitalisation rates 31–68% higher than patients without kidney disease [1]. Uncommon compared with bacterial peritonitis, fungal peritonitis is associated with higher mortality rates (5%–53% vs 0.7%–15%) [4,7] and often results in permanent discontinuation of PD with high morbidity [4,8]. The guidelines emphasise the importance of prompt catheter removal to reduce the high attendant morbidity and mortality [3]. Since laboratory results are often non-specific and mycological information may be delayed, it is important to recognise risk factors, clinical features and laboratory variables that discriminate fungal, from bacterial, peritonitis to guide early initiation of targeted antifungal therapy. Fungal peritonitis is a serious complication of peritoneal dialysis (PD) therapy with the majority of patients ceasing PD permanently. The aims of this study were to identify risk factors and clinical associations that may discriminate between fungal from bacterial peritonitis
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