Fungal Peritonitis Research Articles

Comparative study between spontaneous fungal peritonitis (SFP) and spontaneous bacterial peritonitis (SBP) in patients with end stage liver disease (ESLD)

Background: Bacterial infections in end stage liver disease are common and associated with increased mortality. Although extensive research has elucidated the impact of bacterial infections as the major precipitating event leads to increased frequency of liver-related complications and mortality in these patients. Objective: Evaluating the clinical and laboratory characters, risk factors, and outcome of fungal and bacterial peritonitis in cirrhotic patients with end stage liver disease (ESLD). Patients and Methods: This cross sctional study enrolled 60 patients with liver cirrhosis and ascites. Fifty patients were culture-positive spontaneous peritonitis, including 12 with spontaneous fungal peritonitis (SFP), and 38 culture-positive spontaneous bacterial peritonitis (SBP), and 10 patients without clinical or laboratory evidence of peritonitis as a control group, during the study period, between 1st February 2018 and 30th May 2019. We compared the clinical, laboratory findings, Child–Pugh scores, model for end stage liver disease (MELD) score, risk factors, and mortality rates between patients with spontaneous peritonitis associated with fungal culture-positive ascites, and those with spontaneous peritonitis associated with bacterial culture-positive ascites. Results: Patients of the current study were critically ill. The mean duration of ESLD in the studied patients was 4.75 ± 1.8 year, 57 patients (95.0%) were Child score C, and 3 patients (5%) were Child score B. The mean MELD score was 23.32 ± 5.49. All patients with evidence of peritonitis were Child C, and mean MELD scores were 22.6 ±5.7 and 26.1±4.5 in SBP and SFP groups respectively. Jaundice, GI bleeding and hepatic encephalopathy were significantly for clinical presentation and predictors of mortality in SFP group compared to SBP and control group. Lower levels of hemoglobin (Hb), S. albumin and platelets count and increased level of total leukocytic count (TLC), international normalized ratio (INR), and bilirubin were significantly higher in SFP group compared to SBP and control group. Duration of ESLD and hospital admission was significant in SFP compared to SBP and control group. HCC was evident in SFP group (66.7%) that was highly significant in comparison to SBP (28.9%), and control group (20%). Overall mortality rate among the studied groups was 45%, the mortality rate was significantly increased in SFP group (75%) compared to SBP (42.1%), and control group (20%).The mean MELD score significantly increased in non-survival group compared to survival group . The duration of ESLD significantly increased in non-survival group compared to survival group. Conclusion: Prolonged and severe underlying liver disease with a high Child- Pugh or MELD score, renal impairment, HCC, and onset of severe sepsis have been reported as risk factors in increased mortality in patients with SFP than in SBP. In SFP, mortality was associated not only with the severity of the underlying liver disease, but also with delay in diagnosis and initiation of antifungal therapy.

Peritonitis profile in a cohort of extreme poverty patients on continuous ambulatory peritoneal dialysis-5 year experience from a South Indian public private partnership model PD programme

Introduction Limitations in finance and education is thought to translate into poor technique , understanding and thereby into higher incidence of peritonitis and ultimately poor patient and technique survival. This notion sometimes leads to such patients being denied Continuous Ambulatory Peritoneal Dialysis (CAPD). Methods: In 2013, 20 patients were initiated on CAPD under a Public Private Partnership (PPP) model project in Karnataka province, India. By regulation, they were required to belong to Below Poverty Line (BPL ) category which is a measure of extreme poverty. BPL is the equivalent of earning less than a dollar per day. They were followed up for peritonitis, technique and patient survival besides overall performance. Results: 20 patients were included ( Male: 60%, Mean age 56.7 years, Diabetic Nephropathy 48%). Peritonitis rate was 1 in 33.8 patient –months, with 3 episodes of Fungal Peritonitis (FP) including one of Candida Hemolunii. All FP led to termination of CAPD. Coagulase-Negative Staphylococcus (CoNS) was the most common pathogen isolated , accounting for 60% of the episodes. Technique survival was 15% and patient survival was 20% at 5 years. Cardiovascular disease, sepsis, and malignancy accounted for majority of the deaths. Conclusions: Patients with background of extreme poverty had peritonitis rates comparable to good centres, however patient survival at 5 years was lower. Educational or economic considerations did not seem to be an impediment to successful CAPD.

Evaluation of T2Candida Panel for detection of Candida in peritoneal dialysates.

Fungal peritonitis in the peritoneal dialysis population is difficult to diagnose promptly due to the inherently slow cultivation-based methods currently required for identification of peritonitis pathogens. Because of the moderate risk for severe complications, the need for rapid diagnostics is considerable. One possible solution to this unmet need is the T2Candida Panel, a new technology designed to detect the most common pathogenic Candida spp. directly from whole blood specimens in as little as a few hours. We hypothesized that this technology could be applied to the detection of Candida in peritoneal dialysate, a matrix not currently approved by the Food and Drug Administration for testing by this system. Remnant dialysate samples from three healthy (noninfected) pediatric peritoneal dialysis patients were spiked with Candida glabrata, serially diluted, and tested in triplicate with unaltered dialysate specimens. The assay detected C. glabrata in 100% of spiked dialysate samples across the full spectrum of dilutions tested, and no assay inhibition or cross-reactivity was noted. These findings suggest one of possibly more applications of this technology. The positive clinical implications of this test will continue to be realized as its use is validated in peritoneal dialysate and other patient specimen types.

Utility of Abdominal Imaging in Peritoneal Dialysis Patients Presenting With Peritonitis

Background:Peritonitis remains a major complication in peritoneal dialysis (PD). Abdominal imaging is often performed in the setting of peritonitis to evaluate for concomitant intra-abdominal processes. However, the usefulness of this procedure is unknown.Objective:The aim of this study was to assess the prevalence of abdominal imaging performed in the setting of PD peritonitis and to evaluate clinical parameters associated with abnormal imaging results to identify clinical situations in which radiographic examinations are informative.Design:This is a retrospective cohort study.Setting:The study was conducted at the Toronto General Hospital, Ontario, Canada.Patients:We studied 166 episodes of PD peritonitis in 114 patients between January 1, 2011, and June 30, 2016.Measurements:Baseline demographics, characteristics of PD peritonitis, and characteristics of abdominal imaging performed.Methods:The association between relevant clinical parameters and abnormal abdominal imaging was examined using a univariate and multivariate logistic regression model.Results:Abdominal imaging (computed tomography [CT] scan or ultrasound) was performed in 68 cases (41%). Patients were more likely to undergo imaging if they required hospitalization, were admitted to the intensive care unit (ICU), had polymicrobial or fungal organisms causing peritonitis, had relapsing/recurrent/refractory peritonitis, had an indication for hemodialysis or PD catheter removal, or presented with hypotension, tachycardia, or an elevated serum lactate. Of the imaging performed, abnormalities were found in 32 cases (47%). The most common findings were bowel obstruction, intra-abdominal collection, and biliary abnormalities. In the univariate analysis, ICU admission (43.3% vs 14.3%, P < .01) and need for temporary or permanent hemodialysis (62.5% vs 30.6%, P < .01) were associated with imaging abnormalities. Importantly, the peritonitis organism was not associated with abnormal imaging results. In a multivariate analysis, ICU admission was the only significant clinical parameter associated with imaging abnormalities with an odds ratio (OR) of 4.4 (95% confidence interval [CI]: 1.1-17.4, P = .04).Limitations:Single-center study, small sample size, and lack of detailed information on the exact indications leading to abdominal imaging.Conclusions:Abdominal imaging is commonly performed in the setting of PD peritonitis. Abnormalities are not infrequent and are present in almost half of the cases, with need for ICU admission being the most significant clinical parameter associated with abnormal findings. Therefore, abdominal imaging should be performed in carefully selected patients with PD peritonitis, especially if there is evidence of hemodynamic instability. While the finding of fungal or polymicrobial peritonitis was a driver for abdominal imaging, the presence of these organisms did not predict radiologic abnormalities.

A case of successful treatment of bacterial – fungal peritonitis in a child undergoing peritoneal dialysis

The paper reports on a case of an effective treatment of severe dialysis-caused peritonitis associated with mixed Candida krusei and polyresistant bacterial flora in a 13 year-old patient who had end stage renal disease. A clinical course of peritonitis was being persistent with formation of intraabdominal abscesses. It required massive antibacterial and antifungal therapy and repeated surgeries.

Serum Galactomannan Index for the Rapid Diagnosis of Fungal Peritonitis in Patients With Peritoneal Dialysis

Serum Galactomannan Index for the Rapid Diagnosis of Fungal Peritonitis in Patients With Peritoneal Dialysis

Rhodococcus induced false-positive galactomannan (GM), a biomarker of fungal presentation, in patients with peritoneal dialysis: case reports

BackgroundGalactomannan index (GMI) at a level higher than 0.5 provides high sensitivity and specificity for the diagnosis of fungal peritonitis. Here, we report the false-positive of GMI in peritoneal dialysis (PD) effluent (PDE) due to Rhodococcus peritonitis in PD patients.Case presentationGMI in PDE of case #1 and case #2 were 1.53 and 0.76, respectively, while serum GMI of both cases was less than 0.5. In addition, GMI from the specimens obtained directly from the stationary phase of Rhodococcus colonies were 1.27 and 1.56, which were isolated from case #1 and #2, accordingly.ConclusionHigh GMI in PDE of PD patients is not specific just for fungal infections but may also be secondary to other infections, such as Rhodococcus spp., especially in endemic areas.

2571 Unicentric Castleman Disease as a Cause of Ileal Perforation: A Case Report

INTRODUCTION: Castleman disease is describes a group of heterogenous lymphoproliferative disorders that share histopathologic features. It is divided into Unicentric castleman disease (UCD) and Multicentric Castleman disease. We present a case of a patient with one year history of recurrent small bowel obstruction (SBO), which was found to be due to UCD affecting the mesentery. CASE DESCRIPTION/METHODS: A 75 years old gentleman initially presented one year ago with an episode of SBO. He had no history of abdominal or pelvic surgery. CT scan showed a transition point near the terminal ileum and mesenteric/retroperitoneal lymphadenopathy. Patient underwent a colonoscopy which showed a stenotic ileocecal valve with active colitis in the terminal ileum and ascending colon suggestive of resolving intestinal ischemia. This time, patient was admitted with decreased oral intake due to SBO. He was found to have a low albumin of 0.8 and an AKI on CKD. He also had bilateral pleural effusions and new ascites. He was treated conservatively initially, but he developed new abdominal pain with X ray showing free air under the diaphragm concerning for intestinal perforation. Patient underwent emergent laparotomy, where he had a perforated terminal ileum and multiple large fibrotic lymph nodes in the associated mesentery. Pathology showed proliferation of atretic follicles. There were occasional penetrating capillaries and the mantle lymphocytes have an onion-skin pattern. The interfollicular zones showed increased plasma cells, but not prominent vascular proliferation. CD3 and CD20 stains showed an intact immune-architecture. The overall findings showed a mixed pattern of Castleman lymphadenopathy, with some features of both the hyaline vascular and plasma cell variants. He had IgA of 510 mg/dl and an abnormal SPEP with IgG lambda paraprotein of 0.39 g/dl. His hospital course was complicated by septic shock due to bacterial and fungal peritonitis. Patient eventually went into cardiac arrest and died. DISCUSSION: Mixed variant CD is mostly multicentric, however, some patients with UCD reveal features of both hyaline vascular type and plasma cell type. In this case, apart from abdominal pain and recurrent SBO episodes, there were no other complaints. Acute phase reactants, CBC, and serological testing for HIV, HHV-8, Hepatitis B, Hepatitis C, RPR and PPD were all unremarkable. UCD is usually asymptomatic and generally curable using surgical resection but in this case led to severe complication ending in patient's demise.

2231 Spontaneous Fungal Peritonitis- A Rare Complication of Ascites Secondary to Right Heart Failure: A Case Report

INTRODUCTION: Spontaneous fungal peritonitis is an infection which occurs in patients with liver cirrhosis.Spontaneous fungal peritonitis is uncommon in a patient with cardiac ascites because of high protein content and low risk of infections.We present the second known case of SFP in a patient with cardiogenic ascites. CASE DESCRIPTION/METHODS: 52-year-old female with past medical history of COPD was admitted to the hospital with a two-week history of abdominal pain and dyspnea.Labratory findings showed WBC count of 7,900/mm3, ANC of 6936/mm3, hemoglobin 15.8, platelet count 406 × 103/mm3, creatinine 0.9mg/dL, total bilirubin 3.40 mg/dL, direct bilirubin 2.30 mg/dL, ammonia of 51. Initial imaging of CT abdomen and pelvis showed bilateral pleural effusions, moderate ascites, and liver cirrhosis. ECHO showed left ventricular ejection fraction of 55%, dilated right ventricle, moderate tricuspid regurgitation with right ventricular systolic pressure of 76 mm Hg. Diagnostic and therapeutic ultrasound guided paracentesis was done and 400 mL of fluid was removed and sent for analysis and culture. Patient was empirically started on ceftriaxone for possible spontaneous bacterial peritonitis. Ascitic fluid analysis showed hazy fluid with WBC count of 23,000, 92% of polymorphic cells and 8% of mononuclear cells. Preliminary cultures from ascitic fluid grew Candida glabrata, and patient was started on caspofungin, and diagnosis of spontaneous fungal peritonitis was made. The patient gradually responded to antifungals. DISCUSSION: Cardiac cirrhosis is defined by signs and symptoms of chronic liver disease along with history of heart failure. Ascites due to heart failure is considered low risk for infections because of the high protein content in the ascitic fluid. Ascitic fluid retrieved by diagnostic paracentesis should be analyzed for lactate dehydrogenase, cytology, total cell count and differential, total protein, albumin, bacterial and fungal culture sensitivities. Along with bacterial gram stain and culture sensitivity, fungal stain and culture sensitivities are necessary due to an increasing prevalence of SFP in patients with cirrhosis. Common species causing SFP is Candida albicans, and other causative fungal agents being Candida glabrata, Candida krusei. Risk factors for SFP include elevated Child-Pugh and MELD scores, use of prophylactic antibiotics for SBP, low ascitic fluid protein (&lt; 1 g/dL), hepatorenal syndrome. Treatment with echinocandins is recommended as soon as the diagnosis is made.

2495 Spontaneous Fungal Peritonitis Secondary to Candida glabrata in a Patient With Cardiac Cirrhosis

INTRODUCTION: Spontaneous fungal peritonitis (SFP) is an uncommon, but serious complication of liver cirrhosis. In one study, the one-month mortality rate was 73.3% as compared to 28% in SBP alone. The mortality remains high despite appropriate antifungal therapy partly due to delayed diagnosis. CASE DESCRIPTION/METHODS: We present a case of a 67 years-old male patient who presented with acute confusion and worsening abdominal distension for unknown duration. He has history of heart failure with reduced ejection fraction secondary to ischemic cardiomyopathy and liver cirrhosis presumed secondary to heart failure. He was found to have acute hepatic encephalopathy, anasarca, acute kidney injury, and septic shock. Abdominal exam showed tender, distended abdomen with positive fluid thrill. Spontaneous bacterial peritonitis (SBP) was suspected and ascitic fluid analysis was sent. It reported nucleated cells 3766/uL, 80% neutrophils, SAAG 1.7, glucose &lt;20 mg/dl, and total protein 3.2 g/dl. Computed tomography of abdomen and pelvis without contrast showed massive ascites, but there was no evidence of bowel perforation (Figure 1). He was treated with Vancomycin and Zosyn for SBP and lactulose for hepatic encephalopathy. On day 3, gram stain of ascitic fluid reported budding yeast, and he was started on anidulafungin. The final culture reported Candida glabrata. Bacterial and fungal blood cultures were negative. Despite treatment, his encephalopathy persisted, and he had rapid accumulating ascitic fluid. Ascitic fluid culture was repeated which reported the same. A repeat CT abdomen showed perihepatic hematoma and free intraperitoneal air (Figure 2). He underwent exploratory laparotomy that revealed duodenal perforation. Despite surgical repair and antifungal, septic shock progressed, and patient died from multi-organ failure. Candida glabrata was sensitive to anidulafungin on retrospective review of sensitivity report. DISCUSSION: Although initial ascitic fluid analysis suggested secondary peritonitis, CT scan was negative for perforation or loculated infection. Our case highlights the high mortality rate of Candida peritonitis despite appropriate treatment. It is likely secondary to delayed antifungal and undiagnosed bowel perforations.

2143 A Unique Complication of Gastrostomy Tubes

INTRODUCTION: In 1979 the Gauderer-Ponsky technique was developed to allow endoscopic placement of gastrostomy tubes (G-tubes). The procedure allowed fistulation between the stomach and abdominal wall. G-tubes are often placed for enteral feeding in patients who have either an inability or insufficiency of intake by mouth. Complications of G-tubes are often seen but an overwhelmingly majority of them are minor. At times G-tubes lead to soft tissue &amp; skin infections, colocutaneous fistulas, &amp; visceral perforations. These more serious complications can occur up to 11-15%. Smaller complications such as dislodgement or G-tube dysfunction are far more common. CASE DESCRIPTION/METHODS: A 49 year-old male with a past medical history of traumatic brain injury with placement of a percutaneous endoscopic gastrostomy tube (G-tube) who presented to the ED after pulling out his G-tube. Unable to place the G-tube back at bedside, interventional radiology reinserted under fluoroscopy. After discharge he presented back to the ED with coffee ground emesis &amp; aspiration. He was noted to have klebsiella pneumonia. Despite being appropriately treated for his pneumonia he continued to have worsening septic shock abdominal distention. CT imaging was positive for large collection of fluid, gas, &amp; contrast filling his peritoneum. Emergent exploratory laparotomy found 6L of peritoneal fluid &amp; a perforated fistulous tract draining into his peritoneal cavity. Meanwhile his abdominal viscera was coated with a white film. Labs &amp; cultures confirmed peritonitis caused by klebsiella, enterococcus, &amp; candida. He received antibiotics and antifungal therapy, required multiple washouts, &amp; surgical correction of the perforation with a wedge gastrectomy. DISCUSSION: This patient developed a rare &amp; serious complication after G-tube placement. Dislodging the G-tube in a traumatic fashion caused drainage into his peritoneum. Even though the G-tube was replaced under radiographic guidance he developed a terrible case of peritonitis. The rates of complications are statistically the same in radiographically or endoscopically placed G-tubes. This patient required surgical placement of another G-tube along with and a wedge gastrectomy. This complication of fungal peritonitis &amp; aspiration pneumonia show us that G-tubes are not always benign. Endoscopic, surgical, and radiographic techniques may all have a different approach to ensure good outcomes but a patient’s ability to receive good G-tube care is essential in preventing long term complications.

Pathogenic bacteria and drug resistance of peritoneal dialysis related peritonitis

Objective To investigate the pathogenic bacteria and drug resistance of peritoneal dialysis related peritonitis. Methods Retrospectively analysis of 86 patients From January 2014 to December 2017 with peritoneal dialysis(PD) related peritonitis of the dialysis center of the first affiliated hospital of USTC, included pathogenic bacteria, drug sensitivty test and prognosis was performed. Results Among all the patients, 58 cases cultured positive (67.4%). In culture positive bacteria, 43 gram-positive cocci (74.1%), 6 gram-negative cocci (10.3%) and 9 fungus (15.5%). Staphylococcus epidermidis was the most common gram-positive cocci (22.4%). Bacterium coli was the most common gram-negative bacilli (5.2%). Fungi was mostly found in smooth candida. Drug sensitivty test results indicated that gram-positive cocci had the highest resistance rates of 51.2% to penicillin G, all were sensitive to vancomycin. Gram-negative bacteria had similar resistance rate to aztreonam, ceftriaxone and ciprofloxacin while it had no resistance to amikacin. Among all the patients, 71 cases (82.6%) were cured, 13 cases (16.7%) removed peritoneal dialysis catheter and transferred to hemodialysis, 2 cases cultured positive, but they refused treatment. There were 45 cases peritonitis in the first year of PD, had the rate of 52.3%, that was significantly higher than other dialysis year. Conclusions Gram-positive cocci are still the main pathogens of PD related peritonitis in our dialysis center. The first year of PD is the easiest infection stage, patients should be strengthened education. In empirical treatment, we recommend vancomycin combined with aminoglycosides. Fungal peritonitis is the main causes for patients' dropout of PD. Key words: Peritoneal Dialysis; Peritonitis; Bacteria; Drug Tolerance

Risk factors, clinical features, and short-term prognosis of spontaneous fungal peritonitis in cirrhosis: A matched case-control study.

BACKGROUNDSpontaneous peritonitis is one of the most common infectious complications in cirrhotic patients with ascites. Spontaneous fungal peritonitis (SFP) is a type of spontaneous peritonitis that is a less recognized but devastating complication in end-stage cirrhosis. Although high mortality was previously noted, scant data are available to fully define the factors responsible for the occurrence of SFP and its mortality.AIMTo illustrate the differences between SFP and spontaneous bacterial peritonitis (SBP) and discuss the risk factors for the occurrence of SFP and its short-term mortality.METHODSWe performed a matched case-control study between January 1, 2007 and December 30, 2018. Patients with SFP were included in a case group. Sex-, age-, and time-matched patients with SBP were included in a control group and were further divided into control-1 group (positive bacterial culture) and control-2 group (negative bacterial culture). The clinical features and laboratory parameters, severity models, and prognosis were compared between the case and control groups. Logistic regression analysis was used to determine the risk factors for occurrence, and the Cox regression model was used to identify the predictive factors for short-term mortality of SFP.RESULTSPatients with SFP exhibited more severe systemic inflammation, higher ascites albumin and polymorphonuclear neutrophils, and a worsened 15-d mortality than patients in the control groups. Antibiotic administration (case vs control-1: OR = 1.063, 95%CI: 1.012-1.115, P = 0.014; case vs control-2: OR = 1.054, 95%CI: 1.014-1.095, P = 0.008) remarkably increased the occurrence of SFP or fungiascites. Hepatorenal syndrome (HR = 5.328, 95%CI: 1.050-18.900) and total bilirubin (μmol/L; HR = 1.005, 95%CI: 1.002-1.008) represented independent predictors of SFP-related early mortality.CONCLUSIONLong-term antibiotic administration increases the incidence of SFP, and hepatorenal syndrome and total bilirubin are closely related to short-term mortality.

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

BACKGROUNDSpontaneous 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.AIMTo determine the prevalence of fungal pathogens, management and outcomes (mortality) of SFP in critically ill cirrhotic patients.METHODSStudies 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.RESULTSSix 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%.CONCLUSIONThis 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.

Safety of Laparoscopic Gastrostomy in Children Receiving Peritoneal Dialysis

BackgroundThe preferred method of dialysis for children is chronic peritoneal dialysis (CPD), and these children may require delayed gastrostomy tube (GT) placement. Investigators have reported a high risk of fungal peritonitis, early bacterial peritonitis, and catheter loss when percutaneous endoscopic gastrostomy is performed in children already undergoing CPD. Current International Society for Peritoneal Dialysis guidelines recommend only open GT for these patients. We sought to report the safety of laparoscopic gastrostomy (LG) among children already receiving PD. Materials and methodsWe conducted a retrospective chart review of children who had initiated CPD before GT placement between 2010 and 2017 at our pediatric hospital. Demographic data, clinical details, and peritonitis rates were recorded. Peritonitis was defined as peritoneal WBC count >100/mm3 and >50% neutrophils, with or without a positive peritoneal culture. ResultsTwenty-three subjects had both undergone CPD and had a GT placed in the study period. Of these, 13 had a GT placed after CPD had been initiated. One of these was excluded for open technique and another excluded because of no overlap of GT and PD catheter, leaving 11 for analysis. Median age at the time of LG was 1.32 y and median weight-for-age z-score was −1.86 (IQR −2.9, −1.3). Median days to PD catheter and GT use after LG were 2 (range 0-4) and 1 (range 0-2). Median weight z-score change at 90 d was +0.5 (IQR −0.1, +0.9). All patients received antifungal and antibiotic coverage at time of GT placement. No subjects developed fungal peritonitis or early bacterial peritonitis, although one developed bacterial peritonitis within 30 d. The overall rate of peritonitis after laparoscopic gastrostomy tube was 0.35 episodes/patient-year. This was similar to a rate of 0.45 episodes/patient-year during PD but before laparoscopic gastrostomy tube in the same patients (P = 0.679). Four subjects required periods of hemodialysis, two of which were because of PD catheter removal due to infection. One of the latter was due to a relapse of pre-LG peritonitis and the patient later resumed PD. The other was due to remote post-LG peritonitis and the patient continued hemodialysis until renal transplant, both after 6 mo. ConclusionsWe found that, in children already receiving PD, LG is similar in safety profile, efficacy, and technical principle to open gastrostomy. LG is therefore an appropriate and safe alternative to open gastrostomy in this setting.

Management of fungal peritonitis : a Moroccan single peritoneal dialysis unit experience

Introduction: Fungal peritonitis (PF) in peritoneal dialysis (PD) is a serious infection that involves the functional prognosis of the peritoneum and the patient's vital prognosis. It must benefit from a fast handling but nevertheless not very codified. Each center therefore ensures an individual care of its patients.&#x0D; Materiel and method: The purpose of our study is to describe our 10-year experience through our patients who presented FP. We performed a descriptive retrospective study of FP cases documented in the PD unit.&#x0D; Results: the prevalence of FP was 5,1%, which represent 9 cases. Predominant clinical signs were dialysat turbidity and abdominal pain. FP was primitive for 3 patients. The antifungal therapy used was Fluconazole, which was combined with an increased number of peritoneal exchanges. DP catheter ablation was done for 8 patients with an average delay of 5.5 days. The overall outcome was favorable and 3 patients continued PD. No death or encapsulating peritonitis was a consequence of FP.&#x0D; Discussion and conclusion: FP is an infectious complication in PD. Its’ death rate is elevated; dropping-out of PD rate too is elevated. The favorable evolution of our patients that stayed in PD let us think that it may be possible to maintain more patients in PD after FP.

Performance of Clinical and Biological Diagnostic Tests in Reference to the Recommended Tests for the Management of Fungal Peritonitis in Intensive Care

Performance of Clinical and Biological Diagnostic Tests in Reference to the Recommended Tests for the Management of Fungal Peritonitis in Intensive Care

Unsolved Issues in the Treatment of Spontaneous Peritonitis in Patients with Cirrhosis: Nosocomial Versus Community-acquired Infections and the Role of Fungi.

Historically, spontaneous bacterial peritonitis (SBP) has represented one of the most frequent and relevant infectious complications of advanced liver disease, and this is still valid today. Nevertheless, in recent years the role of fungi as causative pathogens of primary peritonitis in patients with cirrhosis has become not negligible. Another issue is linked with the traditional distinction, instrumental in therapeutic choice, between community-acquired and nosocomial forms, according to the onset. Between these two categories, another one has been introduced: the so-called "healthcare-associated infections". To discuss the most controversial aspects in the management of SBP nowadays in the light of best available evidence. A review of recent literature through MEDLINE was performed. The difference between community-acquired and nosocomial infections is crucial to guide empiric antibiotic therapy, since the site of acquisition impact on the likelihood of multidrug-resistant bacteria as causative agents. Therefore, third-generation cephalosporins cannot be considered the mainstay of treatment in each episode. Furthermore, the distinction between healthcare-associated and nosocomial form seems very subtle, especially in areas wherein antimicrobial resistance is widespread, warranting broad-spectrum antibiotic regimens for both. Finally, spontaneous fungal peritonitis is a not common but actually underestimated entity, linked to high mortality. Especially in patients with septic shock and/or failure of an aggressive antibiotic regimen, the empiric addition of an antifungal agent might be considered. Spontaneous bacterial peritonitis is one of the most important complications in patients with cirrhosis. A proper empiric therapy is crucial to have a positive outcome. In this respect, a careful assessment of risk factors for multidrug-resistant pathogens is crucial. Likewise important, mostly in nosocomial cases, is not to overlook the probability of a fungal ascitic infection, namely a spontaneous fungal peritonitis.

Peritoneal Dialysis-Associated Peritonitis.

Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the prevention and treatment of PD-associated peritonitis have been published by the International Society for Peritoneal Dialysis (ISPD), but there is a substantial variation in clinical practice among dialysis units. Prophylactic antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or catheter infection are key measures to prevent PD-associated peritonitis. When a patient on PD presents with clinical features compatible with PD-associated peritonitis, empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the appropriate microbiologic specimens have been obtained. Intraperitoneal is the preferred route of administration. Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis. Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be adjusted accordingly. A detailed description on the dosage of individual antibiotic can be found in the latest recommendations by the ISPD. The duration of antibiotics is usually 2-3 weeks, depending on the specific organisms identified. Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis. In some patients, a new PD catheter could be inserted after complete resolution of the peritonitis. PD catheter removal should also be considered for refractory exit site or tunnel infections. After the improvement in clinical practice, there is a worldwide trend of reduction in PD-associated peritonitis rate, supporting the use of PD as a first-line dialysis modality.

SAT-106-Prevalence and survival of fungal peritonitis in decompensated cirrhosis

SAT-106-Prevalence and survival of fungal peritonitis in decompensated cirrhosis