Fungal Peritonitis Research Articles

Fungal Peritonitis in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients

Fungal Peritonitis in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients

Peritonitis due to <i>Geotrichum candidum</i> in Continuous Ambulatory Peritoneal Dialysis

This paper is a report of a 34-year-old man with chronic renal failure undergoing Continuous Ambulatory Peritoneal Dialysis which developed peritonitis due to Geotricum candidum. The diagnosis was established by culture of dialysis fluid. The purpose of this report is to provide data on a fungal peritonitis due to a non-common agent.

Retrospective Comparative Study of Spontaneous Peritonitis Associated with Fungal and Bacterial Infection in Patients with Liver Cirrhosis

Objective: Although patients with liver cirrhosis (LC) have a high risk of developing bacterial and fungal infections, few studies have evaluated spontaneous fungal peritonitis (SFP) or fungiascites in this population. Accordingly, we conducted a retrospective comparative study of spontaneous peritonitis associated with fungal (SFP and fungiascites) or bacterial culture-positive ascites [spontaneous bacterial peritonitis (SBP) and bacterascites] in patients with LC.Methods: This study enrolled 73 patients with LC and ascitic culture-positive spontaneous peritonitis, including four, three, 35, and 31 patients with SFP, fungiascites, culture-positive SBP, and bacterascites, respectively. We compared the laboratory findings, Child–Pugh scores, and 1-month mortality rates between patients with fungal disease, i.e., spontaneous peritonitis associated with fungal culture-positive ascites (SFP and fungiascites), and those with bacterial disease, i.e., spontaneous peritonitis associated with bacterial culture-positive ascites (culturepositive SBP and bacterascites).Results: We observed no significant differences in the severity of underlying liver dysfunction and renal impairment between patients with fungal and bacterial disease. However, the 1-month mortality rate was significantly higher in patients with fungal disease than in those with bacterial disease (71.4%, 5/7 vs. 25.8%, 17/66; p= 0.038).Conclusion: In our retrospective study population, spontaneous peritonitis caused by fungi (SFP and fungiascites) was associated with a significantly higher short-term mortality rate compared with that of spontaneous peritonitis caused by bacteria (culture-positive SBP and bacterascites). Further studies are required to investigate the underlying mechanisms and determine the effects of antifungal therapy on mortality.

Prediction of Fungal Infection Development and Their Impact on Survival Using the NACSELD Cohort.

Bacterial infections are associated with negative outcomes in cirrhosis but fungal infections are being increasingly recognized. The objective of this study is to define risk factors for fungal infection development and impact on 30-day survival. In a large, multi-center cirrhotic inpatient cohort, demographics, cirrhosis details, intensive care unit (ICU), organ failures/acute-on-chronic liver failure (ACLF), and 30-day survival were compared between patients without infections and with bacterial infections alone, with those with fungal infections. Variables associated with fungal infection development were determined using multi-variable regression. Ordinal variables (0=no infection, 1=community-acquired bacterial infection, 2=nosocomial bacterial, and 3=fungal infection) were input into a 30-day survival model. A total of 2,743 patients (1,691 no infection, 918 bacterial, and 134 fungal infections) were included. Patients with fungal infection, all of which were nosocomial, were more likely to be admitted with bacterial infections, on spontaneous bacterial peritonitis prophylaxis, and have diabetes and advanced cirrhosis. Bacterial infection types did not predict risk for fungal infections. Multi-variable analysis showed male gender to be protective, whereas diabetes, longer stay, ICU admission, acute kidney injury (AKI), and admission bacterial infection were associated with fungal infection development (area under the curve (AUC)=0.82). Fungal infections were associated with significantly higher ACLF, inpatient stay, ICU admission, and worse 30-day survival. The case fatality rate was 30% with most fungal infections but >50% for fungemia and fungal peritonitis. On a multi-variable analysis, age, AKI, model for end-stage liver disease, ICU admission, and ordinal infection variables impaired survival (P<0.0001, AUC=0.83). Fungal infections are associated with a poor 30-day survival in hospitalized cirrhotic patients compared with uninfected patients, and those with bacterial infections. Patients with diabetes, AKI, and those with an admission bacterial infection form a high-risk subgroup.

Spontaneous peritonitis in critically ill cirrhotic patients: a diagnostic algorithm for clinicians and future perspectives.

Spontaneous peritonitis (SP) is the most common infection among decompensated end-stage liver disease patients. SP is the infection of ascitic fluid (neutrophil ascitic count ≥250/mL) without an alternative focus of abdominal infection. According to the causative agent, clinicians can make the diagnosis of spontaneous bacterial peritonitis or spontaneous fungal peritonitis. The mortality rate is very high, ranging from one-fifth of the patients with spontaneous bacterial peritonitis to four-fifths of the patients with spontaneous fungal peritonitis. An immediate and accurate diagnosis can improve the outcome in end-stage liver disease patients. The aim of this work is to provide physicians with a practical diagnostic guidance for SP diagnosis according to current evidence, in order to improve the management of cirrhotic patients with infected ascitic fluid.

Assessment of Fungal Infection of Peritoneal Fluid in Cirrhotic Ascites

Background and study aim: Spontaneous peritonitis (SP) is the most important infectious complication of cirrhotic patients. The aim of this study is to evaluate the occurrence of fungal infection of peritoneal fluid in cirrhotic patients with ascites. Patients and Methods: Between September 2016 and April 2017, 50 Patients were classified into (SP group) and (non SP group) all patients were subjected to history taking, clinical examination, complete blood count, ESR,CRP, liver profile, kidney function tests, serological tests for viral hepatitis markers, abdominal ultrasonography and diagnostic abdominal paracentesis. The ascitic fluid was subjected to the following: microscobic examination, biochemical examination and microbiological cultures (bacterial and fungal). Results: MELD score was higher in SP group with Mean ± SD 23.08 ± 3.85. Analysis of the results showed that abdominal pain, hepatic encephalopathy and melena were the only significant clinical presentations (chief complaint) in patients with SP compared to non SP group (52%, 40% and 8% respectively). As regard risk factors of ascitic fluid infection, 40% had previous episodes of SP. In SP patients, mean PMN count in ascitic fluid was 675.20 ± 420.02 at the time of diagnosis. Ascitic fluid bacterial culture was positive in only 40% of SP patients. Ascitic fluid fungal culture was positive in only 2 patient (8%) of SP group and negative in all patients of non SP group. The isolated organism was Candida albicans. These 2 patient had proven spontaneous fungal peritonitis owing to the presence of Candida albicans as evidenced by clinical picture of spontaneous peritonitis, high ascitic fluid PMN count and. Conclusion: Spontaneous fungal peritonitis is less common than SBP but usually presented as a severe disease, so, clinical prediction and early detection helps in proper treatment and better prognosis.

Spontaneous fungal peritonitis: a rare but severe complication of liver cirrhosis.

Spontaneous bacterial peritonitis is the most common infectious complication in cirrhosis. Spontaneous fungal peritonitis is rare and remains unknown. In this work, spontaneous fungal peritonitis as well as risk factors and prognosis are characterized. A retrospective case-control study of 253 consecutive admissions by peritonitis in cirrhotic patients was carried out between 2006 and 2015. Comparison of patients with spontaneous fungal peritonitis (cases) and spontaneous bacterial peritonitis with positive microbiologic ascitic fluid culture (controls) was performed. Variables such as sociodemographic and clinical features, cirrhosis etiology, liver dysfunction scores, ascitic and laboratory parameters, invasive procedures, and prognosis were evaluated. Of the 231 patients, eight (3.5%) developed spontaneous fungal peritonitis, 62.5% of cases being coinfected with bacteria. Candida spp. was isolated in 87.5% of cases, mainly Candida albicans (37.5%) and C. krusei (25.0%). Patients with spontaneous fungal peritonitis had higher ascitic fluid lactate dehydrogenase (288.4±266.6 vs. 161.0±179.5; P=0.011), blood leukocyte count (15187.5±5432.3 vs. 10969.8±6949.5; P=0.028), blood urea nitrogen (69.8±3.1 vs. 36.3±25.5; P=0.001), higher number of invasive procedures (colonoscopy: 25.0 vs. 0.8%, P=0.001; urinary catheterization: 87.5 vs. 49.6%, P=0.038; nasogastric intubation: 87.5 vs. 26.9%, P=0.001), and longer duration of hospital stay (30.0±32.9 vs. 18.9±17.0 days; P=0.031). No statistical difference was found between the two groups for Model for End-Stage Liver Disease, Model for End-Stage Liver Disease-sodium, and Child-Pugh scores. Spontaneous fungal peritonitis was associated with a worse prognosis, particularly severe sepsis/septic shock (87.5 vs. 42.8%, P=0.023), admission in the gastroenterology intensive care unit (87.5 vs. 24.4%; P=0.001), and overall (62.5 vs. 31.9%; P=0.039) or 30-day mortality (50.0 vs. 24.4%; P=0.034), with a mean diagnosis-death time of 17.6±11.5 days. Despite being a rare condition, spontaneous fungal peritonitis was associated with worse prognosis and higher mortality than SBP. The ascitic fluid lactate dehydrogenase, blood leukocyte count and urea nitrogen, invasive procedures, and longer admission time were independent risk factors for spontaneous fungal peritonitis.

Cost Effectiveness of Candida Polymerase Chain Reaction Detection and Empirical Antifungal Treatment among Patients with Suspected Fungal Peritonitis in the Intensive Care Unit

BackgroundMortality from intra-abdominal candidiasis in intensive care units (ICUs) is high. It takes many days for peritoneal-fluid fungal culture to become positive, and the recommended empirical antifungal therapy involves excessive costs. Polymerase chain reaction (PCR) should produce results more rapidly than fungal culture. ObjectivesTo perform a cost-effectiveness analysis of the combination of several diagnostic and therapeutic strategies to manage Candida peritonitis in non-neutropenic adult patients in ICUs. MethodsWe constructed a decision tree model to evaluate the cost effectiveness. Cost and effectiveness were taken into account in a 1-year time horizon and from the French National Health Insurance perspective. Six strategies were compared: fluconazole or echinocandin as an empirical therapy, plus diagnosis by fungal culture or detection by PCR of all Candida species, or use of PCR to detect most fluconazole-resistant Candida species (i.e., Candida krusei and Candida glabrata). ResultsThe use of fluconazole empirical treatment and PCR to detect all Candida species is more cost effective than using fluconazole empirical treatment without PCR (incremental cost-effectiveness ratio of €40,055/quality-adjusted life-year). Empirical treatment with echinocandin plus PCR to detect C. krusei and C. glabrata is the most effective strategy, but has an incremental cost-effectiveness ratio of €93,776/quality-adjusted life-year. If the cost of echinocandin decreases, then strategies involving PCR plus empirical echinocandin become more cost-effective. ConclusionsDetection by PCR of all Candida species and of most fluconazole-resistant Candida species could improve the cost-effectiveness of fluconazole and echinocandin given to non-neutropenic patients with suspected peritoneal candidiasis in ICUs.

Apoptosis inhibitor of macrophage ameliorates fungus-induced peritoneal injury model in mice

Fungal peritonitis in a patient on peritoneal dialysis (PD) is a refractory injury accompanied by severe inflammation, predisposing patients to a poor prognosis. Defective clearance of necrotic tissue interferes with amelioration of tissue injury and induces abnormal tissue remodeling. In the recent reports, apoptosis inhibitor of macrophage (AIM, also called CD5L) prevents obesity, hepatocellular carcinoma and acute kidney injury. Here, we investigated potential roles of AIM in prevention of progression of fungal peritonitis models. AIM−/− mice subjected to zymosan-induced peritonitis exhibited progressive inflammation and sustained peritoneal necrosis tissue on day 28 after the disease induction, whereas there was an improvement in AIM+/+ mice. This appeared to be caused by deposition of AIM at the necrotic peritoneum in AIM+/+ mice. In vitro, AIM enhanced the engulfment of necrotic debris by macrophages derived from zymosan-induced peritonitis, M1- and M2a-like bone marrow derived macrophages, as well as by mesothelial cells. In addition, administration of recombinant AIM dramatically ameliorated severe inflammation associated with necrosis in zymosan-induced peritonitis of AIM−/− mice. Our observations suggest that AIM appears to be involved in the repair process of zymosan-induced peritonitis, and thus, could be the basis of development of new therapeutic strategies for PD-related fungal peritonitis.

Risk of spontaneous fungal peritonitis in hospitalized cirrhotic patients with ascites: a systematic review of observational studies and meta-analysis.

Spontaneous fungal peritonitis (SFP) is an infection of ascitic fluid occurring in cirrhotic patients. SFP prevalence varies from 0% to 41% of patients with spontaneous peritonitis (SP) and a positive ascitic fluid culture. Cirrhotic patients with SFP who fail to show improvement with empirical antibiotic therapy, before the identification of the fungal pathogen, have high mortality (89.5-100%). Although the weight of the disease is so dramatic, more recent guidelines on infections in cirrhosis do not consider SFP management. The aim of this meta-analysis was to investigate the association between hospitalization (at least 48-72 hours after admission) and risk of SFP. A literature search was performed on PubMed, Scopus and Web of Science to identify relevant studies published up to March 2, 2017. Only observational studies that specify the etiology of SP were included. Data were pooled using risk difference as a summary measure and corresponding 95% confidence interval (CI). Thirteen cohort studies were included in the meta-analysis (12 retrospective and one prospective). A pooled risk difference, using a random effects model, of nosocomial versus non-nosocomial SFP was 2.9% (95% CI, 0.4% to 5.3%, P=0.024) with a no significant heterogeneity among studies (P=0.090, I²=37%). This meta-analysis suggests that hospitalization is related to a significant increase of SFP risk.

Peritonitis caused by Candida albicans: Rare presentation of a refluxing ureteral stump

Ureteral stump syndrome is a medical condition caused by a refluxing distal ureteral remnant left after nephrectomy. Fungal colonization of the ureteral stump is uncommon and distant site infection is exceptional. We present a unique case of fungal peritonitis in a 13-year-old boy who had a right lower-moiety heminephro-ureterectomy at age three with a ureteral stump that served as reservoir for Candida resulting in the subsequent spontaneous fungal passage to the peritoneum.

Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients.

Peritoneal dialysis (PD) is an important therapy for patients with end-stage kidney disease and is used in more than 200,000 such patients globally. However, its value is often limited by the development of infections such as peritonitis and exit-site and tunnel infections. Multiple strategies have been developed to reduce the risk of peritonitis including antibiotics, topical disinfectants to the exit site and antifungal agents. However, the effectiveness of these strategies has been variable and are based on a small number of randomised controlled trials (RCTs). The optimal preventive strategies to reduce the occurrence of peritonitis remain unclear.This is an update of a Cochrane review first published in 2004. To evaluate the benefits and harms of antimicrobial strategies used to prevent peritonitis in PD patients. We searched the Cochrane Kidney and Transplant's Specialised Register to 4 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. RCTs or quasi-RCTs in patients receiving chronic PD, which evaluated any antimicrobial agents used systemically or locally to prevent peritonitis or exit-site/tunnel infection were included. Two authors independently assessed risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratio (RR) with 95% confidence intervals (CI). Thirty-nine studies, randomising 4435 patients, were included. Twenty additional studies have been included in this update. The risk of bias domains were often unclear or high; risk of bias was judged to be low in 19 (49%) studies for random sequence generation, 12 (31%) studies for allocation concealment, 22 (56%) studies for incomplete outcome reporting, and in 12 (31%) studies for selective outcome reporting. Blinding of participants and personnel was considered to be at low risk of bias in 8 (21%) and 10 studies (26%) for blinding of outcome assessors. It should be noted that blinding of participants and personnel was not possible in many of the studies because of the nature of the intervention or control treatment.The use of oral or topical antibiotic compared with placebo/no treatment, had uncertain effects on the risk of exit-site/tunnel infection (3 studies, 191 patients, low quality evidence: RR 0.45, 95% CI 0.19 to 1.04) and the risk of peritonitis (5 studies, 395 patients, low quality evidence: RR 0.82, 95% CI 0.57 to 1.19).The use of nasal antibiotic compared with placebo/no treatment had uncertain effects on the risk of exit-site/tunnel infection (3 studies, 338 patients, low quality evidence: RR 1.34, 95% CI 0.62 to 2.87) and the risk of peritonitis (3 studies, 338 patients, low quality evidence: RR 0.94, 95% CI 0.67 to 1.31).Pre/perioperative intravenous vancomycin compared with no treatment may reduce the risk of early peritonitis (1 study, 177 patients, low quality evidence: RR 0.08, 95% CI 0.01 to 0.61) but has an uncertain effect on the risk of exit-site/tunnel infection (1 study, 177 patients, low quality evidence: RR 0.36, 95% CI 0.10 to 1.32).The use of topical disinfectant compared with standard care or other active treatment (antibiotic or other disinfectant) had uncertain effects on the risk of exit-site/tunnel infection (8 studies, 973 patients, low quality evidence, RR 1.00, 95% CI 0.75 to 1.33) and the risk of peritonitis (6 studies, 853 patients, low quality evidence: RR 0.83, 95% CI 0.65 to 1.06).Antifungal prophylaxis with oral nystatin/fluconazole compared with placebo/no treatment may reduce the risk of fungal peritonitis occurring after a patient has had an antibiotic course (2 studies, 817 patients, low quality evidence: RR 0.28, 95% CI 0.12 to 0.63).No intervention reduced the risk of catheter removal or replacement. Most of the available studies were small and of suboptimal quality. Only six studies enrolled 200 or more patients. In this update, we identified limited data from RCTs and quasi-RCTs which evaluated strategies to prevent peritonitis and exit-site/tunnel infections. This review demonstrates that pre/peri-operative intravenous vancomycin may reduce the risk of early peritonitis and that antifungal prophylaxis with oral nystatin or fluconazole reduces the risk of fungal peritonitis following an antibiotic course. However, no other antimicrobial interventions have proven efficacy. In particular, the use of nasal antibiotic to eradicate Staphylococcus aureus, had an uncertain effect on the risk of peritonitis and raises questions about the usefulness of this approach. Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered and high quality RCTs to inform decision making about strategies to prevent peritonitis is striking.

Dialysate color and its role in presumptive diagnosis of dimorphic fungi in peritoneal dialysis associated fungal peritonitis

Background: Fungal peritonitis is a rare but serious complication of peritoneal dialysis (PD). Dimorphic fungi are described in peritonitis at a much lower percentage than yeasts are, but their involvement in it is growing.Methods: The study was based on the analysis of available data over a period of 16 years. The sample size was of 421 ESRD patients on CAPD. We retrospectively identified 72 cases of fungal peritonitis. In the present study we assessed the frequency of dimorphic fungi as a single pathogen, its association with the dialysate colour along with the predictors and its impact on the outcome of the patients.Results: In between January 2000 and October 2016, in present retrospective study, we identified 72 episodes of peritoneal dialysis associated with fungal peritonitis. Among the 72 fungal episodes, 83.3% were Candida species, 1.5% were yeast and the remaining 15.2% were dimorphic fungi. The macrolevel observations of dialysate showed greyish, blackish, greenish, pinkish, cloudy, bluish green and cloudy colours that developed due to the pigmentation of fungi and fungal spores. The Aspergillus species predominates amongst the dimorphic fungi. Outcome analysis revealed that the loss of life (14.7%) was more frequent in diabetics while the reinsertion of catheter failed in cases of glomerulonephritis. It was also noticed that de novo infections were more frequent among the diabetics and that the previous bacterial peritonitis episode was the strongest predictor amongst them all.Conclusions: The premise of the current study illustrates the fact that the dialysate colour can be put to use as an early warning system and by combining the macroscopic observations of the dialysate with the results of microscopy and culture, the diagnosis of Fungal peritonitis due to dimorphic fungi will not be missed. Also worth noting is the point that an early assessment of predictors alongside that of an antifungal coverage can lead to a reduction in the rates of morbidity which in turn will shorten the stay in hospital. This will prevent any further nosocomial infection, antifungal resistance and chances of treatment failure.

A rare bacterial and fungal peritoneal dialysis related peritonitis, a case report and review of literature

Peritoneal dialysis (PD) related peritonitis due to atypical organisms commonly occur following prolonged antibiotic exposure in an immune-compromised hosts. Fungal PD peritonitis is a rare cause of PD related peritonitis and is associated with significant morbidity and mortality with poor response to conservative management. Early PD catheter removal is contemplated in fungal PD peritonitis in view of discouraging response to prolonged medical management and high risk of complications including death.

Infectious Disease Pharmaceutical Care: The Role of the Clinical Pharmacists to Improve Clinical Outcomes 2017

Today more than past we need to improve clinical outcomes in the management of infectious disease related to patient in critical conditions (septic shock, sepsis, MOF, invasive fungal infections, HIV, peritonitis, meningitis, endocarditis, osteomyelitis, pneumonia, severe UTI, proteases infections and other). The same way we can see the high efficacy of some new drugs in eradicate severe infectious (as CEPAT), saving cost for transplant. This condition needs today an active role and permanent presence of clinical pharmacist in medical team because these therapies highly involved in patient’s health. The objective of this work is to analyze the role of clinical pharmacist in infectious disease medical team observing some in our opinion relevant publication and the positive effect on clinical outcomes. Infectious disease needs today new management systems to contain the increase of antimicrobial resistance in an era of few new and innovative drug discovered by pharmaceutical industries. Clinical pharmacist can give to the physicians a great help in this field to improve clinical outcomes, reducing toxicity, containing costs but also to preserve the antimicrobial potential of the antimicrobials (as safe-life drugs). These are only some of the many reason to apply the clinical pharmacist competence in patient medical team.

Treatment of Patients with Cirrhosis

Several influential authors in their recent review on the treatment of patients with cirrhosis [1-3] did not mention spontaneous fungal peritonitis (SFP) as a severe complication of liver cirrhosis. Spontaneous peritonitis (SP) is an infection of ascitic fluid of cirrhotics without an alternative intraabdominal source of infection. If an ascitic fluid culture is performed, the growth of bacteria makes diagnosis of spontaneous bacterial peritonitis (SBP), instead the growth of fungi makes diagnosis of SFP4.

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

Background & aimsThe 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 MethodsA total of 80 cirrhotic patients admitted to the hospital with ascitis (June-2013 to April-2015) were followed in this study. ResultsDuring 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%. ConclusionOur 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 Fungal Peritonitis as a Complication of Cardiogenic Ascites

Spontaneous Fungal Peritonitis as a Complication of Cardiogenic Ascites

Fungal peritonitis in patients undergoing peritoneal dialysis (PD) in Brazil: molecular identification, biofilm production and antifungal susceptibility of the agents.

This paper presents data on fungal peritonitis (FP) in patients undergoing peritoneal dialysis (PD) at the University Hospital of Botucatu Medical School, São Paulo, Brazil. In a total of 422 patients, 30 developed FP, from which the medical records and the fungal isolates of 23 patient cases were studied. All patients presented abdominal pain, cloudy peritoneal effluent, needed hospitalization, had the catheter removed and were treated with fluconazole or fluconazole plus 5-flucitosine; six of them died due to FP. Concerning the agents, it was observed that Candida parapsilosis was the leading species (9/23), followed by Candida albicans (5/23), Candida orthopsilosis (4/23), Candida tropicalis (3/23), Candida guilliermondii (1/23), and Kodamaea ohmeri (1/23). All the isolates were susceptible to amphotericin B, voriconazole and caspofungin whereas C. albicans isolates were susceptible to all antifungals tested. Resistance to fluconazole was observed in three isolates of C. orthopsilosis, and dose-dependent susceptibility to this antifungal was observed in two isolates of C. parapsilosis and in the K. ohmeri isolate. Biofilm production estimates were high or moderate in most isolates, especially in C. albicans species, and low in C. parapsilosis species, with a marked variation among the isolates. This Brazilian study reinforces that FP in PD is caused by a diverse group of yeasts, most prevalently C. parapsilosis sensu stricto species. In addition, they present significant variation in susceptibility to antifungals and biofilm production, thus contributing to the complexity and severity of the clinical features.

PD Associated Recurrent Peritonitis

If patient's immunity impairs due to the first episode of peritonitis, leads in some cases to another episode of peritonitis from a completely different organism, implying a different cause is known as Recurrent Peritonitis. Method: The study is based on the analysis of our data over a period of 16 years. The sample size was of 402 ESRD patients on CAPD. We retrospectively identified 20 cases of recurrent peritonitis, examined the demographic features, spectrum of pathogens and the outcome. Result: We analyzed 20 patients of recurrent peritonitis in which 11 (55%) patients developed aerobic peritonitis, 6 (30%) developed anaerobic peritonitis and 3 (15%) patients developed fungal peritonitis. We observed that all the three categories of recurrent peritonitis were predominantly found in the cases of diabetic nephropathy. Data were significant at 0.05 levels. When analysis was done between primary diagnosis and outcome, p value was 0.094 which was very near to significance; it might become significant if sample size would high. Aggressive combination therapy was given to the patients to avoid relapse and recurrent peritonitis. Outcome of anaerobic Recurrent Peritonitis is more dreaded than outcome of aerobic Recurrent Peritonitis. Worst outcome was observed when both the primary and Recurrent Peritonitis were due to fungal pathogens.Conclusion: The study illustrates that if, any symptom of peritonitis reappears after initial positive response within the fourth week of therapy of a prior episode, we should think of recurrent peritonitis. Hence, we should advice repeat counts and culture testing of dialysate, to avoid further recurrence and relapse.