1
|
Berger JM, Lötsch F, Berghoff AS, Lamm WW, Preusser M, Jeryczynski G. A case of fungal peritonitis in a patient with paramalignant ascites. Med Mycol Case Rep 2024; 45:100660. [PMID: 39149598 PMCID: PMC11325765 DOI: 10.1016/j.mmcr.2024.100660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 08/17/2024] Open
Abstract
Here, we present the case of a patient with a metastatic neuroendocrine tumor with cytologically negative ascites treated for spontaneous bacterial peritonitis (SBP). Ascitic cultures remained negative for bacterial growth but were positive for Candida albicans 8 days after SBP diagnosis. ß-D-glucan was only positive in ascites, while being negative in blood. Blood cultures remained negative throughout the whole admission. Fungal peritonitis presumably originated from an impending bowl perforation or an increasing vascular permeability caused by an increase in VEGF secondary to diffuse infiltration by the underlying malignant disease.
Collapse
Affiliation(s)
- Julia M Berger
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Personalized Immunotherapy, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Felix Lötsch
- Clinical Division of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Personalized Immunotherapy, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Wolfgang W Lamm
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Personalized Immunotherapy, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Georg Jeryczynski
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
2
|
Chen T, Chen G, Wang G, Treeprasertsuk S, Lesmana CRA, Lin HC, Al-Mahtab M, Chawla YK, Tan SS, Kao JH, Yuen MF, Lee GH, Alcantara-Payawal D, Nakayama N, Abbas Z, Jafri W, Kim DJ, Choudhury A, Mahiwall R, Hou J, Hamid S, Jia J, Bajaj JS, Wang F, Sarin SK, Ning Q. Expert consensus on the diagnosis and treatment of end-stage liver disease complicated by infections. Hepatol Int 2024; 18:817-832. [PMID: 38460060 DOI: 10.1007/s12072-023-10637-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/22/2023] [Indexed: 03/11/2024]
Abstract
End-stage liver disease (ESLD) is a life-threatening clinical syndrome and when complicated with infection the mortality is markedly increased. In patients with ESLD, bacterial or fungal infection can induce or aggravate the occurrence or progression of liver decompensation. Consequently, infections are among the most common complications of disease deterioration. There is an overwhelming need for standardized protocols for early diagnosis and appropriate management for patients with ESLD complicated by infections. Asia Pacific region has the largest number of ESLD patients, due to hepatitis B and the growing population of alcohol and NAFLD. Concomitant infections not only add to organ failure and high mortality but also to financial and healthcare burdens. This consensus document assembled up-to-date knowledge and experience from colleagues across the Asia-Pacific region, providing data on the principles as well as evidence-based current working protocols and practices for the diagnosis and treatment of patients with ESLD complicated by infections.
Collapse
Affiliation(s)
- Tao Chen
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China
| | - Guang Chen
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China
| | - Guiqiang Wang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing, China
| | - Sombat Treeprasertsuk
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University, and Thai Red Cross, Bangkok, Thailand
| | - Cosmas Rinaldi Adithya Lesmana
- Internal Medicine, Hepatobiliary Division, Dr. Captor Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, DKI, Indonesia
| | - Han-Chieh Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mamun Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Yogesh K Chawla
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Soek-Siam Tan
- Department of Hepatology, Hospital Selayang, Selangor Darul Ehsan, Malaysia
| | - Jia-Horng Kao
- Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Guan-Huei Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | | | - Nobuaki Nakayama
- Department of Gastroenterology & Hepatology, Saitama Medical University, Saitama, Japan
| | - Zaigham Abbas
- Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Dong-Joon Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, Chuncheon, Korea
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Mahiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jinlin Hou
- Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Guangdong Provincial Clinical Research Center for Viral Hepatitis, Key Laboratory of Infectious Diseases Research in South China, Ministry of Education, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Saeed Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - J S Bajaj
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Fusheng Wang
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Qin Ning
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China.
| |
Collapse
|
3
|
Patel K, Twohig P, Peeraphatdit T, Stohs EJ, Samson K, Smith L, Patel J, Manatsathit W. Outcomes and factors associated with cryptococcal disease among cirrhotics: A study of the national inpatient sample 2005 to 2014. Clin Res Hepatol Gastroenterol 2024; 48:102337. [PMID: 38609048 DOI: 10.1016/j.clinre.2024.102337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Cryptococcal disease (CD) confers a higher mortality in cirrhotic patients compared to non-cirrhotic patients. Factor association for CD in cirrhotic patients is poorly understood. Our aim was to determine the incidence, demographic, and comorbidities associated with CD among cirrhotic patients in the United States (US). METHOD Retrospective analysis of admissions of cirrhotic patients, with or without CD, using the National Inpatient Sample (NIS) database from 2005 to 2014. The number of admissions were reported in raw and weighted frequencies. The trends of CD among cirrhotic patients and overall CD were evaluated. Rao-Scott chi-square, t-tests, and multivariate logistic regressions were performed to evaluate variables and CD among cirrhotic patients. RESULTS There were 886,962 admissions for cirrhosis, and 164 of these with CD. By adjusted odds ratio (AOR), CD was more often associated with cirrhosis in Southern (2.95; 95 % CI 1.24, 7.02) and Western regions (4.45; 95 % CI 1.91, 10.37), Hispanic patients (1.80; 95 % CI 1.01, 3.20), and patients with chronic kidney disease (CKD) (3.13; 95 % CI 2.09, 4.69). Of note, CD in cirrhotic patients was associated with higher inpatient mortality (AOR of 3.89, 95 % CI 2.53, 5.99), longer length of stay (9.87 vs. 4.88 days), and a higher total charge ($76,880 vs. $ 37,227) when compared to cirrhotic patients without CD. DISCUSSION Patients with cirrhosis admitted with CD have a high inpatient mortality. The geographical location and CKD were important factors associated with CD among cirrhotic patients. Autoimmune liver diseases and immunosuppression did not appear to increase the risk of CD.
Collapse
Affiliation(s)
- Kishan Patel
- Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Patrick Twohig
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Thoetchai Peeraphatdit
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Erica J Stohs
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kaeli Samson
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Lynette Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jay Patel
- Department of Internal Medicine, University of Connecticut Medical Center, Farmington, CA 06030, USA
| | - Wuttiporn Manatsathit
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198, USA.
| |
Collapse
|
4
|
Lilly EA, Bender BE, Noverr MC, Fidel PL. Protection against lethal sepsis following immunization with Candida species varies by isolate and inversely correlates with bone marrow tissue damage. Infect Immun 2023; 91:e0025223. [PMID: 37702509 PMCID: PMC10580931 DOI: 10.1128/iai.00252-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 09/14/2023] Open
Abstract
Protection against lethal Candida albicans (Ca)/Staphylococcus aureus (Sa) intra-abdominal infection (IAI)-mediated sepsis can be achieved by a novel form of trained innate immunity (TII) involving Gr-1+ myeloid-derived suppressor cells (MDSCs) that are induced by inoculation (immunization) with low virulence Candida species [i.e., Candida dubliniensis (Cd)] that infiltrate the bone marrow (BM). In contrast, more virulent Candida species (i.e., C. albicans), even at sub-lethal inocula, fail to induce similar levels of protection. The purpose of the present study was to test the hypothesis that the level of TII-mediated protection induced by Ca strains inversely correlates with damage in the BM as a reflection of virulence. Mice were immunized by intraperitoneal inoculation with several parental and mutant strains of C. albicans deficient in virulence factors (hyphal formation and candidalysin production), followed by an intraperitoneal Ca/Sa challenge 14 d later and monitored for sepsis and mortality. Whole femur bones were collected 24 h and 13 d after immunization and assessed for BM tissue/cellular damage via ferroptosis and histology. While immunization with standard but not sub-lethal inocula of most wild-type C. albicans strains resulted in considerable mortality, protection against lethal Ca/Sa IAI challenge varied by strain was usually less than that for C. dubliniensis, with no differences observed between parental and corresponding mutants. Finally, levels of protection afforded by the Ca strains were inversely correlated with BM tissue damage (R 2 = -0.773). TII-mediated protection against lethal Ca/Sa sepsis induced by Candida strain immunization inversely correlates with BM tissue/cellular damage as a reflection of localized virulence.
Collapse
Affiliation(s)
- Elizabeth A. Lilly
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Breah E. Bender
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Mairi C. Noverr
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Paul L. Fidel
- Center of Excellence in Oral and Craniofacial Biology, Louisiana State University Health Sciences Center School of Dentistry, New Orleans, Louisiana, USA
| |
Collapse
|
5
|
Li G, Li Q, Zhang C, Yu Q, Li Q, Zhou X, Yang R, Yang X, Liu H, Yang Y. The impact of gene polymorphism and hepatic insufficiency on voriconazole dose adjustment in invasive fungal infection individuals. Front Genet 2023; 14:1242711. [PMID: 37693307 PMCID: PMC10484623 DOI: 10.3389/fgene.2023.1242711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Voriconazole (VRZ) is a broad-spectrum antifungal medication widely used to treat invasive fungal infections (IFI). The administration dosage and blood concentration of VRZ are influenced by various factors, posing challenges for standardization and individualization of dose adjustments. On the one hand, VRZ is primarily metabolized by the liver, predominantly mediated by the cytochrome P450 (CYP) 2C19 enzyme. The genetic polymorphism of CYP2C19 significantly impacts the blood concentration of VRZ, particularly the trough concentration (Ctrough), thereby influencing the drug's efficacy and potentially causing adverse drug reactions (ADRs). Recent research has demonstrated that pharmacogenomics-based VRZ dose adjustments offer more accurate and individualized treatment strategies for individuals with hepatic insufficiency, with the possibility to enhance therapeutic outcomes and reduce ADRs. On the other hand, the security, pharmacokinetics, and dosing of VRZ in individuals with hepatic insufficiency remain unclear, making it challenging to attain optimal Ctrough in individuals with both hepatic insufficiency and IFI, resulting in suboptimal drug efficacy and severe ADRs. Therefore, when using VRZ to treat IFI, drug dosage adjustment based on individuals' genotypes and hepatic function is necessary. This review summarizes the research progress on the impact of genetic polymorphisms and hepatic insufficiency on VRZ dosage in IFI individuals, compares current international guidelines, elucidates the current application status of VRZ in individuals with hepatic insufficiency, and discusses the influence of CYP2C19, CYP3A4, CYP2C9, and ABCB1 genetic polymorphisms on VRZ dose adjustments and Ctrough at the pharmacogenomic level. Additionally, a comprehensive summary and analysis of existing studies' recommendations on VRZ dose adjustments based on CYP2C19 genetic polymorphisms and hepatic insufficiency are provided, offering a more comprehensive reference for dose selection and adjustments of VRZ in this patient population.
Collapse
Affiliation(s)
- Guolin Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qinhui Li
- Department of Medical, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Changji Zhang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qin Yu
- College of Pharmacy, Southwest Medical University, Luzhou, China
| | - Qi Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoshi Zhou
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rou Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xuerong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hailin Liu
- Department of Pharmacy, The People’s Hospital of Chongqing Liangjiang New Area, Chongqing, China
| | - Yong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| |
Collapse
|
6
|
Oliva A, De Rosa FG, Mikulska M, Pea F, Sanguinetti M, Tascini C, Venditti M. Invasive Candida infection: epidemiology, clinical and therapeutic aspects of an evolving disease and the role of rezafungin. Expert Rev Anti Infect Ther 2023; 21:957-975. [PMID: 37494128 DOI: 10.1080/14787210.2023.2240956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/21/2023] [Accepted: 07/21/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Invasive Candida Infections (ICIs) have undergone a series of significant epidemiological, pathophysiological, and clinical changes during the last decades, with a shift toward non-albicans species, an increase in the rate of exogenous infections and clinical manifestations ranging from candidemia to an array of highly invasive and life-threatening clinical syndromes. The long-acting echinocandin rezafungin exhibits potent in-vitro activity against most wild-type and azole-resistant Candida spp. including C.auris. AREAS COVERED The following topics regarding candidemia only and ICIs were reviewed and addressed: i) pathogenesis; ii) epidemiology and temporal evolution of Candida species; iii) clinical approach; iv) potential role of the novel long-acting rezafungin in the treatment of ICIs. EXPERT OPINION Authors' expert opinion focused on considering the potential role of rezafungin in the evolving context of ICIs. Rezafungin, which combines a potent in-vitro activity against Candida species, including azole-resistant strains and C.auris, with a low likelihood of drug-drug interactions and a good safety profile, may revolutionize the treatment of candidemia/ICI. Indeed, it may shorten the length of hospital stays when clinical conditions allow and extend outpatient access to treatment of invasive candidiasis, especially when prolonged treatment duration is expected.
Collapse
Affiliation(s)
- Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, University of Turin, Infectious Diseases, City of Health and Sciences, Turin, Italy
| | - Malgorzata Mikulska
- Division of Infectious Diseases Department of Health Sciences (DISSAL), University of Genoa IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Maurizio Sanguinetti
- Department of Laboratory Sciences and Infectious Diseases, Fondazione Policlinico Universitario "A. Gemelli"; IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Carlo Tascini
- Infectious Diseases Clinic: Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
7
|
Varda B, Alani M, Ahmed S. A Rare Case of Spontaneous Fungal Peritonitis Caused by Candida lusitaniae in a Patient With Necrotizing Pancreatitis. Cureus 2023; 15:e40237. [PMID: 37435273 PMCID: PMC10332884 DOI: 10.7759/cureus.40237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Candida lusitaniae is a rare cause of peritonitis most commonly associated with peritoneal dialysis patients. Pancreatitis is one possible cause of ascites with a low serum ascites albumin gradient. Herein, we present a case of spontaneous fungal peritonitis caused by Candida lusitaniae in a patient with necrotizing pancreatitis. The patient was treated with antifungal medication, while her pancreatitis was managed endoscopically with necrosectomy. She improved clinically and was discharged in stable condition.
Collapse
Affiliation(s)
- Bianca Varda
- Internal Medicine, St. Joseph's Hospital and Medical Center, Phoenix, USA
- Internal Medicine, Loyola University Medical Center, Chicago, USA
| | | | - Shifat Ahmed
- Gastroenterology, Creighton University School of Medicine, St. Joseph's Hospital and Medical Center, Phoenix, USA
| |
Collapse
|
8
|
Jiang Y, Fan C, Dang Y, Zhao W, Lv L, Lou J, Li L, Ding H. Clinical Characteristics and Early Diagnosis of Spontaneous Fungal Peritonitis/Fungiascites in Hospitalized Cirrhotic Patients with Ascites: A Case-Control Study. J Clin Med 2023; 12:jcm12093100. [PMID: 37176540 PMCID: PMC10179646 DOI: 10.3390/jcm12093100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/24/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Spontaneous fungal peritonitis (SFP) and fungiascites is less well-recognized and described in patients with liver cirrhosis. The aims of this study were to determine the clinical characteristics, prognosis, and risk factors of cirrhotic patients with SFP/fungiascites and to improve early differential diagnosis with spontaneous bacterial peritonitis (SBP). METHODS This was a retrospective case-control study of 54 cases of spontaneous peritonitis in cirrhotic patients (52 SFP and 2 fungiascites) with fungus-positive ascitic culture. Fifty-four SBP cirrhotic patients with bacteria-positive ascitic culture were randomly enrolled as a control group. A nomogram was developed for the early differential diagnosis of SFP and fungiascites. RESULTS Hospital-acquired infection was the main cause of SFP/fungiascites. Of the 54 SFP/fungiascites patients, 31 (57.41%) patients carried on with the antifungal treatment, which seemed to improve short-term (30-days) mortality but not long-term mortality. Septic shock and HCC were independent predictors of high 30-day mortality in SFP/fungiascites patients. We constructed a predictive nomogram model that included AKI/HRS, fever, (1,3)-β-D-glucan, and hospital-acquired infection markers for early differential diagnosis of SFP/fungiascites in cirrhotic patients with ascites from SBP, and the diagnostic performance was favorable, with an AUC of 0.930 (95% CI: 0.874-0.985). CONCLUSIONS SFP/fungiascites was associated with high mortality. The nomogram established in this article is a useful tool for identifying SFP/fungiascites in SBP patients early. For patients with strongly suspected or confirmed SFP/fungiascites, timely antifungal therapy should be administered.
Collapse
Affiliation(s)
- Yingying Jiang
- Department of Hepatology and Gastroenterology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Chunlei Fan
- Department of Hepatology and Gastroenterology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Yan Dang
- Clinical Laboratory Center, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Wenmin Zhao
- Department of Hepatology and Gastroenterology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Lingna Lv
- Department of Hepatology and Gastroenterology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Jinli Lou
- Clinical Laboratory Center, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Lei Li
- Department of Hepatology and Gastroenterology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Huiguo Ding
- Department of Hepatology and Gastroenterology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| |
Collapse
|
9
|
Hasa E, Hartmann P, Schnabl B. Liver cirrhosis and immune dysfunction. Int Immunol 2022; 34:455-466. [PMID: 35792761 PMCID: PMC9447994 DOI: 10.1093/intimm/dxac030] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/27/2022] [Indexed: 01/05/2023] Open
Abstract
Cirrhosis is end-stage liver disease resulting from various etiologies and is a common cause of death worldwide. The progression from compensated to decompensated cirrhosis to acute-on-chronic liver failure (ACLF) is due to multiple factors, including continuation of alcohol use or continued exposure to other toxins, an imbalance of the gut microbiota (dysbiosis), increased gut permeability and a disrupted immune response. This disrupted immune response is also named cirrhosis-associated immune dysfunction, which is characterized by worsening systemic inflammation with concomitant immune paralysis, as liver disease deteriorates. This review highlights central immunologic events during the exacerbation of cirrhosis and characterizes the different immune cell populations involved therein.
Collapse
|
10
|
Ning Q, Chen T, Wang G, Xu D, Yu Y, Mao Q, Li T, Li L, Li J, Lu X, Li J, Li Z, Zhang W, Xiao Y, Meng Q, Mi Y, Shang J, Yu Y, Zhao Y, Zhao C, Zhao H, Huang J, Peng J, Tang H, Tang X, Hu J, Hu B, Guo W, Zheng B, Chen B, Zhang Y, Wei J, Sheng J, Chen Z, Wang M, Xie Q, Wang Y, Wang FS, Hou J, Duan Z, Wei L, Jia J. Expert Consensus on Diagnosis and Treatment of End-Stage Liver Disease Complicated with Infections. INFECTIOUS DISEASES & IMMUNITY 2022; 2:168-178. [DOI: 10.1097/id9.0000000000000055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Abstract
End-stage liver disease (ESLD) is a life-threatening clinical syndrome that markedly increases mortality in patients with infections. In patients with ESLD, infections can induce or aggravate the occurrence of liver decompensation. Consequently, infections are among the most common complications of disease progression. There is a lack of working procedure for early diagnosis and appropriate management for patients with ESLD complicated by infections as well as local and international guidelines or consensus. This consensus assembled up-to-date knowledge and experience across Chinese colleagues, providing data on principles as well as working procedures for the diagnosis and treatment of patients with ESLD complicated by infections.
Collapse
Affiliation(s)
- Qin Ning
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Tao Chen
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Guiqiang Wang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing 100034, China
| | - Dong Xu
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yanyan Yu
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing 100034, China
| | - Qing Mao
- Department of Infectious Diseases, Southwest Hospital, Army Medical University, Chongqing 400038, China
| | - Taisheng Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jun Li
- Department of Infectious Disease, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Xiaoju Lu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jiabin Li
- Department of Infectious Diseases, First Affiliated Hospital of Anhui Medical University, Hefei 230031, China
| | - Zhiwei Li
- Department of Infectious Diseases, Shengjing Hospital, Affiliated Hospital of China Medical University, Shenyang 110801, China
| | - Wenhong Zhang
- Department of Infectious Diseases, Institute of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Qinghua Meng
- Department of Severe Liver Diseases, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Yuqiang Mi
- Nankai University Second People's Hospital, Tianjin 300071, China
| | - Jia Shang
- Department of Infectious Disease, People's Hospital of Henan Province, Zhengzhou 450003, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310020, China
| | - Yingren Zhao
- Department of Infectious Diseases, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Caiyan Zhao
- Department of Infectious Diseases, Third Affiliated Hospital of Hebei Medical University, Shijiazhuang 050051, China
| | - Hong Zhao
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing 100034, China
| | - Jianrong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jie Peng
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Xiaoping Tang
- Research Institute of Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou 510060, China
| | - Jinhua Hu
- Liver Failure Treatment and Research Center, The Fifth Medical Center, China PLA General Hospital, Beijing 100039, China
| | - Bijie Hu
- Department of Infectious Diseases, Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Wei Guo
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Bo Zheng
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing 100034, China
| | - Baiyi Chen
- Department of Infectious Diseases, The First Hospital of China Medical University, Shenyang 110002, China
| | - Yuexin Zhang
- Center of Infectious Diseases, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Jia Wei
- Department of Infectious Disease, The Second People's Hospital, Kunming 650201, China
| | - Jifang Sheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Zhi Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Minggui Wang
- Department of Infectious Diseases, Institute of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Yuming Wang
- Department of Infectious Diseases, Southwest Hospital, Army Medical University, Chongqing 400038, China
| | - Fu-Sheng Wang
- Liver Failure Treatment and Research Center, The Fifth Medical Center, China PLA General Hospital, Beijing 100039, China
| | - Jinlin Hou
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Zhongping Duan
- Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Lai Wei
- Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Peking University Hepatology Institute, Peking University People's Hospital, Beijing 100044, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medial University; Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | | |
Collapse
|
11
|
Verma N, Singh S, Roy A, Valsan A, Garg P, Pradhan P, Chakrabarti A, Singh M. Cirrhosis and fungal infections-a cocktail for catastrophe: A systematic review and meta-analysis with machine learning. Mycoses 2022; 65:844-858. [PMID: 35713607 DOI: 10.1111/myc.13482] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We evaluated the magnitude and factors contributing to poor outcomes among cirrhosis patients with fungal infections (FIs). METHODS We searched PubMed, Embase, Ovid and WOS and included articles reporting mortality in cirrhosis with FIs. We pooled the point and relative-risk (RR) estimates of mortality on random-effects meta-analysis and explored their heterogeneity (I2 ) on subgroups, meta-regression and machine learning (ML). We assessed the study quality through New-Castle-Ottawa Scale and estimate-asymmetry through Eggers regression. (CRD42019142782). RESULTS Of 4345, 34 studies (2134 patients) were included (good/fair/poor quality: 12/21/1). Pooled mortality of FIs was 64.1% (95% CI: 55.4-72.0, I2 : 87%, p < .01), which was 2.1 times higher than controls (95% CI: 1.8-2.5, I2 :89%, p < .01). Higher CTP (MD: +0.52, 95% CI: 0.27-0.77), MELD (MD: +2.75, 95% CI: 1.21-4.28), organ failures and increased hospital stay (30 vs. 19 days) were reported among cases with FIs. Patients with ACLF (76.6%, RR: 2.3) and ICU-admission (70.4%, RR: 1.6) had the highest mortality. The risk was maximum for pulmonary FIs (79.4%, RR: 1.8), followed by peritoneal FIs (68.3%, RR: 1.7) and fungemia (55%, RR: 1.7). The mortality was higher in FIs than in bacterial (RR: 1.7) or no infections (RR: 2.9). Estimate asymmetry was evident (p < 0.05). Up to 8 clusters and 5 outlier studies were identified on ML, and the estimate-heterogeneity was eliminated by excluding such studies. CONCLUSIONS A substantially worse prognosis, poorer than bacterial infections in cirrhosis patients with FIs, indicates an unmet need for improving fungal diagnostics and therapeutics in this population. ACLF and ICU admission should be included in the host criteria for defining IFIs.
Collapse
Affiliation(s)
- Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shreya Singh
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akash Roy
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun Valsan
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratibha Garg
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pranita Pradhan
- Indian Council of Medical Research Center for evidence based child health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Meenu Singh
- Indian Council of Medical Research Center for evidence based child health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
12
|
Demir M, Lang S, Hartmann P, Duan Y, Martin A, Miyamoto Y, Bondareva M, Zhang X, Wang Y, Kasper P, Bang C, Roderburg C, Tacke F, Steffen HM, Goeser T, Kruglov A, Eckmann L, Stärkel P, Fouts DE, Schnabl B. The fecal mycobiome in non-alcoholic fatty liver disease. J Hepatol 2022; 76:788-799. [PMID: 34896404 PMCID: PMC8981795 DOI: 10.1016/j.jhep.2021.11.029] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Studies investigating the gut-liver axis have largely focused on bacteria, whereas little is known about commensal fungi. We characterized fecal fungi in patients with non-alcoholic fatty liver disease (NAFLD) and investigated their role in a fecal microbiome-humanized mouse model of Western diet-induced steatohepatitis. METHODS We performed fungal internal transcribed spacer 2 sequencing using fecal samples from 78 patients with NAFLD, 16 controls and 73 patients with alcohol use disorder. Anti-Candida albicans (C. albicans) IgG was measured in blood samples from 17 controls and 79 patients with NAFLD. Songbird, a novel multinominal regression tool, was used to investigate mycobiome changes. Germ-free mice were colonized with feces from patients with non-alcoholic steatohepatitis (NASH), fed a Western diet for 20 weeks and treated with the antifungal amphotericin B. RESULTS The presence of non-obese NASH or F2-F4 fibrosis was associated with a distinct fecal mycobiome signature. Changes were characterized by an increased log-ratio for Mucor sp./Saccharomyces cerevisiae (S. cerevisiae) in patients with NASH and F2-F4 fibrosis. The C. albicans/S. cerevisiae log-ratio was significantly higher in non-obese patients with NASH when compared with non-obese patients with NAFL or controls. We observed a different fecal mycobiome composition in patients with NAFLD and advanced fibrosis compared to those with alcohol use disorder and advanced fibrosis. Plasma anti-C. albicans IgG was increased in patients with NAFLD and advanced fibrosis. Gnotobiotic mice, colonized with human NASH feces and treated with amphotericin B were protected from Western diet-induced steatohepatitis. CONCLUSIONS Non-obese patients with NAFLD and more advanced disease have a different fecal mycobiome composition to those with mild disease. Antifungal treatment ameliorates diet-induced steatohepatitis in mice. Intestinal fungi could be an attractive target to attenuate NASH. LAY SUMMARY Non-alcoholic fatty liver disease is one of the most common chronic liver diseases and is associated with changes in the fecal bacterial microbiome. We show that patients with non-alcoholic fatty liver disease and more severe disease stages have a specific composition of fecal fungi and an increased systemic immune response to Candida albicans. In a fecal microbiome-humanized mouse model of Western diet-induced steatohepatitis, we show that treatment with antifungals reduces liver damage.
Collapse
Affiliation(s)
- Münevver Demir
- Department of Hepatology and Gastroenterology, Campus Virchow Clinic and Campus Charité Mitte, Charité University Medicine, Berlin, Germany
| | - Sonja Lang
- University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department of Gastroenterology and Hepatology, Cologne, Germany,Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Phillipp Hartmann
- Department of Medicine, University of California San Diego, La Jolla, CA, USA,Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Yi Duan
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Anna Martin
- University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department of Gastroenterology and Hepatology, Cologne, Germany
| | - Yukiko Miyamoto
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Marina Bondareva
- Belozerskiy Research Institute for Physical and Chemical Biology and Faculty of Bioengineering and Bioinformatics, M.V. Lomonosov Moscow State University, Moscow, 119991, Russia,Chronic Inflammation Lab, German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
| | - Xinlian Zhang
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Yanhan Wang
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Philipp Kasper
- University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department of Gastroenterology and Hepatology, Cologne, Germany
| | - Corinna Bang
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, 24105 Kiel, Germany
| | - Christoph Roderburg
- Department of Hepatology and Gastroenterology, Campus Virchow Clinic and Campus Charité Mitte, Charité University Medicine, Berlin, Germany,Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Virchow Clinic and Campus Charité Mitte, Charité University Medicine, Berlin, Germany
| | - Hans-Michael Steffen
- University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department of Gastroenterology and Hepatology, Cologne, Germany
| | - Tobias Goeser
- University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department of Gastroenterology and Hepatology, Cologne, Germany
| | - Andrey Kruglov
- Belozerskiy Research Institute for Physical and Chemical Biology and Faculty of Bioengineering and Bioinformatics, M.V. Lomonosov Moscow State University, Moscow, 119991, Russia,Chronic Inflammation Lab, German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
| | - Lars Eckmann
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Peter Stärkel
- St. Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Derrick E. Fouts
- Department of Genomic Medicine, J. Craig Venter Institute, Rockville, MD, USA
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, CA, USA; Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA.
| |
Collapse
|
13
|
Lahmer T, Peçanha-Pietrobom PM, Schmid RM, Colombo AL. Invasive fungal infections in acute and chronic liver impairment: A systematic review. Mycoses 2021; 65:140-151. [PMID: 34837414 DOI: 10.1111/myc.13403] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 12/18/2022]
Abstract
Patients with acute and chronic liver impairment are susceptible to invasive fungal infections such as candidemia and invasive pulmonary aspergillosis as a result of cirrhosis-associated immune dysfunction, humoral immunodeficiency, cell-mediated dysfunction and systemic inflammation. Besides classical risk factors for invasive fungal infection, acute-on-chronic liver failure, corticosteroid use, gastrointestinal bleeding, and prophylactic use of antibiotics are all additional conditions which are related to the potential development of fungal infections. Therefore, high-risk patients should be carefully followed by microbiological surveillance including cultures but also by imaging and fungal biomarkers for providing early diagnosis. Echinocandins are still the mainstay and first line antifungal therapy in cases of invasive candidiasis. Due to concerns of liver toxicity and in cases of renal impairment liposomal amphotericin B is a suitable alternative to voriconazole in patients with invasive pulmonary aspergillosis. Although, data of isavucoanzole and posaconazole use in those patients are also promising more specific studies in the subgroup of patients with liver impairment are needed. Especially, due to the late diagnosis and multiple organ dysfunction usually present in patients with liver impairment morbidity and mortality rates remain high. Based on the broad spectrum of diverse reports with varying content and quality and in some cases lack of evidence we performed a systematic review on this topic.
Collapse
Affiliation(s)
- Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen, Universität München, Munich, Germany
| | - Paula M Peçanha-Pietrobom
- Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen, Universität München, Munich, Germany
| | - Arnaldo Lopes Colombo
- Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| |
Collapse
|
14
|
Knooihuizen SAI, Alexander NJ, Hopke A, Barros N, Viens A, Scherer A, Atallah NJ, Dagher Z, Irimia D, Chung RT, Mansour MK. Loss of Coordinated Neutrophil Responses to the Human Fungal Pathogen, Candida albicans, in Patients With Cirrhosis. Hepatol Commun 2021; 5:502-515. [PMID: 33681682 PMCID: PMC7917271 DOI: 10.1002/hep4.1645] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/02/2020] [Accepted: 10/26/2020] [Indexed: 12/31/2022] Open
Abstract
Neutrophils are the most abundant white blood cell in the body and are key participants in the defense against fungal infections. Fungal infections occur often in patients with cirrhosis and are associated with increased 30-day and 90-day mortality. Previous studies have shown that specific neutrophil functions are abnormal in patients with cirrhosis, although the extent of neutrophil dysfunction is not well understood. We tested the ability of neutrophils from 21 hospitalized patients with cirrhosis and 23 healthy control patients to kill Candida albicans, a common fungal pathogen in patients with cirrhosis. Using an assay, we also measured the ability of neutrophils to coordinate multicellular, synchronized control of C. albicans hyphae through a process known as swarming. We found that neutrophils from patients with cirrhosis have significantly decreased fungicidal capacity compared with healthy control neutrophils (53% vs. 74%, P < 0.0001) and diminished ability to control hyphal growth normalized as a ratio to healthy control (0.22 vs. 0.65, P < 0.0001). Moreover, serum from patients with cirrhosis decreases the ability of healthy control neutrophils to kill C. albicans (from 60% to 41%, P < 0.003). Circulating concentration of the inflammatory cytokines tumor necrosis factor α, interleukin-6, and interleukin-8 were found to be significantly elevated in patients with cirrhosis compared to healthy controls. Following pretreatment with granulocyte-colony stimulating factor and granulocyte-macrophage colony-stimulating factor, neutrophil function was restored to almost that of healthy controls. Conclusion: Our data establish profound neutrophil dysfunction against, and altered swarming to, C. albicans in patients with cirrhosis. This dysfunction can be partially reversed with cytokine augmentation ex vivo.
Collapse
Affiliation(s)
- Sally A I Knooihuizen
- Department of MedicineMassachusetts General HospitalBostonMAUSA.,Harvard Medical SchoolBostonMAUSA
| | | | - Alex Hopke
- Harvard Medical SchoolBostonMAUSA.,Department of SurgeryCenter for Engineering in MedicineMassachusetts General HospitalBostonMAUSA.,Shriners Burns HospitalBostonMAUSA
| | - Nicolas Barros
- Department of MedicineMassachusetts General HospitalBostonMAUSA.,Harvard Medical SchoolBostonMAUSA.,Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
| | - Adam Viens
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
| | - Allison Scherer
- Department of MedicineMassachusetts General HospitalBostonMAUSA.,Harvard Medical SchoolBostonMAUSA.,Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
| | - Natalie J Atallah
- Department of MedicineMassachusetts General HospitalBostonMAUSA.,Harvard Medical SchoolBostonMAUSA.,Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
| | - Zeina Dagher
- Department of MedicineMassachusetts General HospitalBostonMAUSA.,Harvard Medical SchoolBostonMAUSA.,Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
| | - Daniel Irimia
- Harvard Medical SchoolBostonMAUSA.,Department of SurgeryCenter for Engineering in MedicineMassachusetts General HospitalBostonMAUSA.,Shriners Burns HospitalBostonMAUSA
| | - Raymond T Chung
- Department of MedicineMassachusetts General HospitalBostonMAUSA.,Harvard Medical SchoolBostonMAUSA.,Liver Center and Gastrointestinal DivisionMassachusetts General HospitalBostonMAUSA
| | - Michael K Mansour
- Department of MedicineMassachusetts General HospitalBostonMAUSA.,Harvard Medical SchoolBostonMAUSA.,Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
| |
Collapse
|
15
|
Ferreira da Silva AC, Cunha-Silva M, Ferraz Mazo D, Mana MF, Vicente de Paula R, de Ataíde EC, Boin IDFSF, Stucchi RSB, Sevá-Pereira T. Cryptococcal peritonitis in patients on the liver transplant waitlist: Reporting two cases with opposite outcomes. Transpl Infect Dis 2021; 23:e13583. [PMID: 33583111 DOI: 10.1111/tid.13583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
Cryptococcus neoformans is rarely associated with peritonitis in cirrhotic patients; nevertheless, it has a high mortality rate. Early diagnosis and prompt treatment may be the determining prognostic factors. This is a report of two patients awaiting a liver transplant who had opposite outcomes after the diagnosis of spontaneous cryptococcal peritonitis. In Patient 1, the fungal culture was positive in the blood and ascites. She had a poor evolution and died, which was likely caused by the delayed diagnosis and concomitant bacterial infections. In Patient 2, the fungus was found in the ascites, urine, and cerebrospinal fluid cultures. Antifungal treatment was effective. He underwent a liver transplant on the 83rd day of antifungal therapy and is still alive 1 year later. It is important to suspect fungal etiology when there is a lack of response to antibiotics in patients with decompensated cirrhosis and spontaneous peritonitis, and physicians must be aware of leukocyte count in the ascitic fluid, which is not so high in these cases. This report also emphasizes the need for the routine use of blood culture bottles for microbiological analysis of the ascitic fluid, as it was helpful to diagnose fungal peritonitis in both cases.
Collapse
Affiliation(s)
| | - Marlone Cunha-Silva
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil.,Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil
| | - Daniel Ferraz Mazo
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Mauy Frujuello Mana
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | | | - Elaine Cristina de Ataíde
- Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil.,Department of Surgery, University of Campinas (Unicamp), Campinas, Brazil
| | - Ilka de Fátima Santana Ferreira Boin
- Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil.,Department of Surgery, University of Campinas (Unicamp), Campinas, Brazil
| | - Raquel Silveira Bello Stucchi
- Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil.,Division of Infectious Diseases, University of Campinas (Unicamp), Campinas, Brazil
| | - Tiago Sevá-Pereira
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil.,Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil
| |
Collapse
|
16
|
Cryptococcus: A Rare Cause of Parotid Abscess in Liver Cirrhosis. Case Reports Hepatol 2020; 2020:8849448. [PMID: 33282423 PMCID: PMC7685856 DOI: 10.1155/2020/8849448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 11/01/2020] [Accepted: 11/06/2020] [Indexed: 12/29/2022] Open
Abstract
A 61-year-old man with decompensated liver cirrhosis presented with a parotid mass. Fine-needle aspiration of the parotid gland revealed Cryptococcus neoformans. Lumbar puncture confirmed cryptococcal meningitis. Multiple splenic lesions with radiographic features consistent with cryptococcal splenic abscesses were also seen. Despite antifungal therapy, the patient died 17 days after infection was confirmed. This is the first report of a cryptococcal parotid abscess in a patient with liver cirrhosis.
Collapse
|
17
|
Current Status and Prospects of Spontaneous Peritonitis in Patients with Cirrhosis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3743962. [PMID: 32724800 PMCID: PMC7364234 DOI: 10.1155/2020/3743962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/03/2020] [Indexed: 12/14/2022]
Abstract
Spontaneous bacterial peritonitis (SBP) is a common cirrhotic ascites complication which exacerbates the patient's condition. SBP is caused by gram-negative bacilli and, to a lesser extent, gram-positive cocci. Hospital-acquired infections show higher levels of drug-resistant bacteria. Geographical location influences pathogenic bacteria distribution; therefore, different hospitals in the same country record different bacteria strains. Intestinal changes and a weak immune system in patients with liver cirrhosis lead to bacterial translocation thus causing SBP. Early diagnosis and timely treatment are important in SBP management. When the treatment effect is not effective, other rare pathogens should be explored.
Collapse
|
18
|
Cryptococcosis in Liver Transplant Candidates and Recipients. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00399-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
19
|
Allaire M, Cadranel JF, Nguyen TTN, Garioud A, Zougmore H, Heng R, Perignon C, Ollivier-Hourmand I, Dao T. Management of infections in patients with cirrhosis in the context of increasing therapeutic resistance: A systematic review. Clin Res Hepatol Gastroenterol 2020; 44:264-274. [PMID: 31706985 DOI: 10.1016/j.clinre.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/23/2019] [Accepted: 10/04/2019] [Indexed: 02/04/2023]
Abstract
Patients with cirrhosis are prone to develop bacterial infections, which consist in one of the major precursors of Acute-on-Chronic Liver Failure (ACLF) and are responsible for a high mortality rate. In recent years, the management of bacterial infections in patients with cirrhosis has become increasingly complicated due to a change in bacterial ecology associated with a higher rate of cocci gram positive bacteria in Europe and America along with the emergence of a multidrug-resistant (MDR) and extensively drug-resistant (XDR) bacteria leading to a decrease in the efficacy of empirical strategies based on the administration of third-generation cephalosporins. MDR and XDR now account for about 40% of the infections worldwide, and up to 70% in India. Among them, the most common ones are extended-spectrum beta-lactamase producing (ESBL-P) bacteria, carbapenem-resistant enterobacteriaceae (CRE), Methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). An early diagnosis associated to an empirical antibiotic adapted to the site of infection and potential bacterial resistance is now crucial in order to improve the chances of survival and contain the resistance phenomenon. Moreover, a fungal infection must always be discussed in these high-risks patients, especially in the absence of clinical improvement under appropriate antibiotic treatment. In this review, we will focus on the emerging threat of MDR and XDR organisms, as well as fungal infections, in order to better adapt the therapeutic management of cirrhotic patients with infections.
Collapse
Affiliation(s)
- Manon Allaire
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France; Unité Inserm-U1149, Centre de recherche sur l'inflammation, 75018 Paris, France.
| | - Jean-François Cadranel
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Thi Thu Nga Nguyen
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
| | - Armand Garioud
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Honore Zougmore
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Ratmony Heng
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Claire Perignon
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
| | | | - Thông Dao
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
| |
Collapse
|
20
|
Liu CR, Li YP, Feng DD, Dang SS. Hot topics and difficult problems in diagnosis and treatment of end-stage liver disease with fungal infection. Shijie Huaren Xiaohua Zazhi 2020; 28:203-209. [DOI: 10.11569/wcjd.v28.i6.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with end stage liver disease (ESLD) accompanied by fungal infection are clinically common because of long-term hospitalization, imbalance of immune function regulation, common bacterial infections, and invasive operations. Because of its atypical manifestations, it is not easy to detect fungal infection early. Once ESLD is combined with fungal infection, it often induces or aggravates disease progression and increases mortality. This article reviews the progress in the research of epidemiology, risk factors, clinical manifestations, and treatment methods for fungal infection in ESLD patients with an aim to provide reference for clinicians.
Collapse
Affiliation(s)
- Chen-Rui Liu
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, Shaanxi Province, China
| | - Ya-Ping Li
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, Shaanxi Province, China
| | - Dan-Dan Feng
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, Shaanxi Province, China
| | - Shuang-Suo Dang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, Shaanxi Province, China
| |
Collapse
|
21
|
Maraolo AE, Scotto R, Zappulo E, Pinchera B, Schiano Moriello N, Nappa S, Buonomo AR, Gentile I. Novel strategies for the management of bacterial and fungal infections in patients with liver cirrhosis: focus on new antimicrobials. Expert Rev Anti Infect Ther 2020; 18:191-202. [PMID: 32011191 DOI: 10.1080/14787210.2020.1725473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Liver cirrhosis is a frequent condition caused by different etiologies. Bacterial and fungal infections are common complications, representing an independent prognostic stage in patients with cirrhosis, dramatically worsening their clinical outcomes.Areas covered: The present review article addresses manifold points and to this purpose an inductive literature search of MEDLINE database through PubMed was performed. First, it provides an overview on the mechanisms underlying immune disfunctions in patients with cirrhosis, who are prone to develop infections being at higher risk than the general population. Second, commonest types of bacterial and fungal infections in patients with advanced liver disease are described, focusing on their deleterious impact as decompensating events. Third, the rise of multidrug-resistant (MDR) bacteria and fungi as causative agents of infection in cirrhotic subjects is illustrated. Eventually, the most promising novel therapeutic options against MDR pathogens and fungi are reviewed.Expert opinion: The management of bacterial and fungal infections in patients with cirrhosis is difficult, due to the frequent co-existence of renal impairment, low platelet count and other conditions that limit the antimicrobial choice. New antibacterial and antifungal compounds may overcome this issue by providing a better tolerability profile, along with equal or superior efficacy compared with older drugs.
Collapse
Affiliation(s)
- Alberto E Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Riccardo Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Biagio Pinchera
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Nicola Schiano Moriello
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Salatore Nappa
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Antonio Riccardo Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| |
Collapse
|
22
|
Barnett AE, Brust KB. Cirrhosis, gastrointestinal bleed, and cryptococcal peritonitis. Proc (Bayl Univ Med Cent) 2020; 33:195-198. [PMID: 32313460 DOI: 10.1080/08998280.2020.1723361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/16/2020] [Accepted: 01/27/2020] [Indexed: 01/31/2023] Open
Abstract
Disseminated Cryptococcus neoformans infection rarely causes peritonitis in non-HIV-infected patients but does affect cirrhotic patients. Diagnostic challenges delay treatment, and mortality is high. We performed a literature search of proven cryptococcal peritonitis cases in HIV-negative adults with underlying cirrhosis, included our own case, and collected demographic, infection risk factor, diagnostic, treatment, and outcomes data. We identified 16 articles and 21 cases. Most patients were men. Alcohol abuse was the leading cause of underlying cirrhosis (n = 10, 48%). Eight (38%) patients experienced an upper gastrointestinal bleed (UGIB) within a month before peritonitis presentation. Peritoneal fluid analysis was abnormal and lymphocytic predominant. Half the patients were fungemic. When performed, peritoneal fluid cryptococcal antigen (CrAg) test results were positive. Amphotericin B was the primary treatment. Mortality was high at 76%. In conclusion, C. neoformans is an opportunistic pathogen that causes peritonitis in non-HIV, cirrhotic patients. People with recent UGIB seem to be at risk. Cryptococcus species infection should be suspected in patients with clinical signs and symptoms of spontaneous bacterial peritonitis whose lymphocytic-predominant peritoneal fluid and cultures are negative for bacterial growth. Peritoneal CrAg testing expedites diagnosis because growth on fungal media is slow. Mortality remains high, despite standard therapy with amphotericin B.
Collapse
Affiliation(s)
- Amy E Barnett
- Department of Internal Medicine, Baylor Scott & White Medical Center - TempleTempleTexas
| | - Karen B Brust
- Division of Infectious Diseases, Department of Internal Medicine, Baylor Scott & White Medical Center - TempleTempleTexas
| |
Collapse
|
23
|
Lang S, Duan Y, Liu J, Torralba MG, Kuelbs C, Ventura-Cots M, Abraldes JG, Bosques-Padilla F, Verna EC, Brown RS, Vargas V, Altamirano J, Caballería J, Shawcross D, Lucey MR, Louvet A, Mathurin P, Garcia-Tsao G, Ho SB, Tu XM, Bataller R, Stärkel P, Fouts DE, Schnabl B. Intestinal Fungal Dysbiosis and Systemic Immune Response to Fungi in Patients With Alcoholic Hepatitis. Hepatology 2020; 71:522-538. [PMID: 31228214 PMCID: PMC6925657 DOI: 10.1002/hep.30832] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023]
Abstract
Chronic alcohol consumption causes increased intestinal permeability and changes in the intestinal microbiota composition, which contribute to the development and progression of alcohol-related liver disease. In this setting, little is known about commensal fungi in the gut. We studied the intestinal mycobiota in a cohort of patients with alcoholic hepatitis, patients with alcohol use disorder, and nonalcoholic controls using fungal-specific internal transcribed spacer amplicon sequencing of fecal samples. We further measured serum anti-Saccharomyces cerevisiae antibodies (ASCA) as a systemic immune response to fungal products or fungi. Candida was the most abundant genus in the fecal mycobiota of the two alcohol groups, whereas genus Penicillium dominated the mycobiome of nonalcoholic controls. We observed a lower diversity in the alcohol groups compared with controls. Antibiotic or steroid treatment was not associated with a lower diversity. Patients with alcoholic hepatitis had significantly higher ASCA levels compared to patients with alcohol use disorder and to nonalcoholic controls. Within the alcoholic hepatitis cohort, patients with levels of at least 34 IU/mL had a significantly lower 90-day survival (59%) compared with those with ASCA levels less than 34 IU/mL (80%) with an adjusted hazard ratio of 3.13 (95% CI, 1.11-8.82; P = 0.031). Conclusion: Patients with alcohol-associated liver disease have a lower fungal diversity with an overgrowth of Candida compared with controls. Higher serum ASCA was associated with increased mortality in patients with alcoholic hepatitis. Intestinal fungi may serve as a therapeutic target to improve survival, and ASCA may be useful to predict the outcome in patients with alcoholic hepatitis.
Collapse
Affiliation(s)
- Sonja Lang
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Yi Duan
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| | - Jinyuan Liu
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | | | - Claire Kuelbs
- J. Craig Venter Institute, La Jolla, California, USA
| | - Meritxell Ventura-Cots
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh Liver Research Center, Pittsburgh, Pennsylvania, USA
| | - Juan G. Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Francisco Bosques-Padilla
- Hospital Universitario, Departamento de Gastroenterología, Universidad Autonoma de Nuevo Leon, Monterrey, México
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA
| | - Robert S. Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Victor Vargas
- Liver Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Jose Altamirano
- Liver Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Caballería
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Liver Unit, Hospital Clinic, Barcelona, Spain
| | - Debbie Shawcross
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, King's College Hospital, London, UK
| | - Michael R. Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, WI, USA
| | - Alexandre Louvet
- Service des Maladies de L'appareil Digestif et Unité INSERM, Hôpital Huriez, Lille, France
| | - Philippe Mathurin
- Service des Maladies de L'appareil Digestif et Unité INSERM, Hôpital Huriez, Lille, France
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA, and Section of Digestive Diseases, VA-CT Healthcare System, West Haven, CT, USA
| | - Samuel B. Ho
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| | - Xin M. Tu
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - Ramon Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh Liver Research Center, Pittsburgh, Pennsylvania, USA
| | - Peter Stärkel
- St. Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | | | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| |
Collapse
|
24
|
Patel D, Iqbal AM, Mubarik A, Zafar F, Siddiqui SM, Jupalli A, Mitzov NP, Muddassir S. Spontaneous Fungal Peritonitis as a Rare Complication of Ascites Secondary to Cardiac Cirrhosis: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1526-1529. [PMID: 31619662 PMCID: PMC6818645 DOI: 10.12659/ajcr.917757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/15/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spontaneous fungal peritonitis (SFP) is a life-threatening infection which occurs more commonly in patients with liver failure. SFP is not as common as spontaneous bacterial peritonitis (SBP) and has higher mortality rates due to late recognition and difficulty in differentiation between SFP and SBP. Spontaneous fungal peritonitis is extremely uncommon in patients with cardiac ascites due to a high protein content, which predisposes to a low risk of infections. CASE REPORT This report presents a rare case of spontaneous fungal peritonitis in a patient with cardiogenic ascites. To the best of our knowledge, this is the second known case of SFP occurring in a patient with cardiac cirrhosis. The patient did not respond to initiation of SBP treatment and after ascitic fluid grew Candida glabrata, the diagnosis of SFP was made. The patient's clinical status improved after initiation of intravenous caspofungin. CONCLUSIONS SFP should be a differential diagnosis in patients who have cardiac or liver cirrhosis, who are not improving with empirical antibiotic therapy for spontaneous bacterial peritonitis.
Collapse
|
25
|
Gonzalez-Cordero AF, Malavé-Sánchez M, Vergara-Gómez M, Franqui-Rivera H. Spontaneous Fungal Peritonitis. JACC Case Rep 2019; 1:372-375. [PMID: 31840136 PMCID: PMC6908944 DOI: 10.1016/j.jaccas.2019.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This report presents a case of spontaneous fungal peritonitis (SFP) in a patient with cardiogenic ascites. Physicians need to be aware of this life-threatening condition because early suspicion of SFP can improve survival. (Level of Difficulty: Intermediate.)
Collapse
|
26
|
Facciorusso A, Antonino M, Orsitto E, Sacco R. Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art. Expert Rev Gastroenterol Hepatol 2019; 13:751-759. [PMID: 31304804 DOI: 10.1080/17474124.2019.1644167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Spontaneous bacterial peritonitis represents a frequent and severe complication in cirrhotic patients with ascites. In daily practice, the diagnosis of spontaneous bacterial peritonitis might be challenging in the absence of the typical signs and symptoms of infection such as fever or leukocytosis. Areas covered: Aim of this review is to revise the current state of the art on primary and secondary spontaneous bacterial peritonitis. Literature search in Medline/Pubmed was performed. Expert opinion: Historically, gram-negative bacteria were the most frequent etiologic agents of spontaneous bacterial peritonitis, with Escherichia coli and Klebsiella spp. being the most frequently isolated bacteria. However, major changes in this regard occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria. In particular, the increasing prevalence of quinolone-resistant bacteria challenged the prominent role of norfloxacin in spontaneous bacterial peritonitis prevention. Given the high mortality rate and the risk of developing the hepatorenal syndrome, prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis).
Collapse
Affiliation(s)
- Antonio Facciorusso
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Matteo Antonino
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Eugenio Orsitto
- b Department of Radiology, Azienda Ospedaliero-Universitaria Pisana , Pisa , Italy
| | - Rodolfo Sacco
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| |
Collapse
|
27
|
Tariq T, Irfan FB, Farishta M, Dykstra B, Sieloff EM, Desai AP. Spontaneous fungal peritonitis: Micro-organisms, management and mortality in liver cirrhosis-A systematic review. World J Hepatol 2019; 11:596-606. [PMID: 31388401 PMCID: PMC6669191 DOI: 10.4254/wjh.v11.i7.596] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/15/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023] Open
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.
Collapse
Affiliation(s)
- Tooba Tariq
- Department of Internal Medicine, Western Michigan University, Kalamazoo, MI 49008, United States
| | - Furqan B Irfan
- College of Osteopathic Medicine, Michigan State University, WEast Lansing, MI 48824, United States
| | - Mehdi Farishta
- Department of Internal Medicine, Western Michigan University, Kalamazoo, MI 49008, United States
| | - Brian Dykstra
- Department of Pulmonary and Critical Care Medicine, Western Michigan University, Kalamazoo, MI 49008, United States
| | - Eric Martin Sieloff
- Department of Internal Medicine, Western Michigan University, Kalamazoo, MI 49008, United States
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| |
Collapse
|
28
|
Spectrum of Trained Innate Immunity Induced by Low-Virulence Candida Species against Lethal Polymicrobial Intra-abdominal Infection. Infect Immun 2019; 87:IAI.00348-19. [PMID: 31085710 PMCID: PMC6652762 DOI: 10.1128/iai.00348-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/14/2022] Open
Abstract
Polymicrobial intra-abdominal infections (IAI) are clinically prevalent and cause significant morbidity and mortality, especially those involving fungi. Our laboratory developed a mouse model of polymicrobial IAI and demonstrated that coinfection with Candida albicans and Staphylococcus aureus (C. albicans/S. aureus) results in 80 to 90% mortality in 48 to 72 h due to robust local and systemic inflammation. Polymicrobial intra-abdominal infections (IAI) are clinically prevalent and cause significant morbidity and mortality, especially those involving fungi. Our laboratory developed a mouse model of polymicrobial IAI and demonstrated that coinfection with Candida albicans and Staphylococcus aureus (C. albicans/S. aureus) results in 80 to 90% mortality in 48 to 72 h due to robust local and systemic inflammation. Surprisingly, inoculation with Candida dubliniensis and S. aureus resulted in minimal mortality, and rechallenge of mice with lethal C. albicans/S. aureus conferred >90% protection up to 60 days postinoculation. Protection was mediated by Gr-1+ polymorphonuclear leukocytes, indicating a novel form of trained innate immunity (TII). The purpose of this study was to determine the microbial requirements and spectrum of innate-mediated protection. In addition to Candida dubliniensis, several other low-virulence Candida species (C. glabrata, C. auris, and C. albicansefg1Δ/Δ cph1Δ/Δ) and Saccharomyces cerevisiae conferred significant protection with or without S. aureus. For C. dubliniensis-mediated protection, hyphal formation was not required, with protection conferred as early as 7 days after primary challenge but not at 120 days, and also following multiple lethal C. albicans/S. aureus rechallenges. This protection also extended to a lethal intravenous (i.v.) C. albicans challenge but had no effect in the C. albicans vaginitis model. Finally, studies revealed the ability of the low-virulence Candida species that conferred protection to invade the bone marrow by 24 h post-primary challenge, with a positive correlation between femoral bone marrow fungal infiltration at 48 h and protection upon rechallenge. These results support and further extend the characterization of this novel TII in protection against lethal fungal-bacterial IAI and sepsis.
Collapse
|
29
|
Verma N, Singh S, Taneja S, Duseja A, Singh V, Dhiman RK, Chakrabarti A, Chawla YK. Invasive fungal infections amongst patients with acute-on-chronic liver failure at high risk for fungal infections. Liver Int 2019; 39:503-513. [PMID: 30276951 DOI: 10.1111/liv.13981] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 09/12/2018] [Accepted: 09/25/2018] [Indexed: 12/14/2022]
Abstract
AIMS To study the prevalence, risk factors, role of serum biomarkers for diagnosis and impact of invasive fungal infections (IFIs) in patients with acute-on-chronic liver failure (ACLF). METHODS An analysis of IFI in patients with ACLF (EASL criteria) was conducted retrospectively. The diagnosis of IFI in clinically suspected patients was based on EORTC/MSG criteria. The demographical, clinical, laboratory details and outcomes were analysed. RESULTS Out of 264 patients with ACLF, 54 (20.4%) patients with suspicion of IFI were evaluated and IFI was diagnosed in 39 (14.7%). Invasive candidiasis was documented in 25 (64.1%) and invasive aspergillosis in 14 (35.8%). The most common source of infection was respiratory (n = 13) followed by renal (n = 7) and spontaneous fungal peritonitis (n = 6). On univariate analysis, diabetes mellitus, hemodialysis, prior antibiotic use, cerebral and respiratory organ failures, Chronic Liver Failure Consortium (CLIF-OF and CLIF-C ACLF) scores were predictors for development of IFI (P < 0.05). On multivariate analysis, hemodialysis and prior antibiotics use predicted the development of IFI (P < 0.05). Non-survivors were more likely to have IFI (P = 0.029), high CLIF-OF and CLIF-C ACLF scores (P < 0.001; for both) and higher 1,3-β D Glucan (BDG) levels (P = 0.009). The sensitivity, specificity, and AUROC of BDG (80 pg/mL) and Galactomannan index (GMI [0.5]) for diagnosing IFI were 97.4%, 60%, 0.770% and 43.6%, 100%, 0.745 respectively. CONCLUSIONS Invasive fungal infections constitutes an important cause of mortality in ACLF patients. BDG and GMI can be useful markers to guide antifungal therapy in patients at high risk for IFI.
Collapse
Affiliation(s)
- Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shreya Singh
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha K Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Yogesh K Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
30
|
Marciano S, Díaz JM, Dirchwolf M, Gadano A. Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies. Hepat Med 2019; 11:13-22. [PMID: 30666172 PMCID: PMC6336019 DOI: 10.2147/hmer.s164250] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.
Collapse
Affiliation(s)
- Sebastián Marciano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Juan Manuel Díaz
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Melisa Dirchwolf
- Hepatology Unit, Hospital Privado de Rosario, Santa Fe, Argentina
| | - Adrián Gadano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| |
Collapse
|
31
|
Maraolo AE, Buonomo AR, Zappulo E, Scotto R, Pinchera B, Gentile I. Unsolved Issues in the Treatment of Spontaneous Peritonitis in Patients with Cirrhosis: Nosocomial Versus Community-acquired Infections and the Role of Fungi. Rev Recent Clin Trials 2019; 14:129-135. [PMID: 30514194 DOI: 10.2174/1574887114666181204102516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 06/09/2023]
Abstract
INTRODUCTION 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". OBJECTIVE To discuss the most controversial aspects in the management of SBP nowadays in the light of best available evidence. METHODS A review of recent literature through MEDLINE was performed. RESULTS 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. CONCLUSION 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.
Collapse
Affiliation(s)
- Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Antonio Riccardo Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Riccardo Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Biagio Pinchera
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| |
Collapse
|
32
|
Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24:4311-4329. [PMID: 30344417 PMCID: PMC6189843 DOI: 10.3748/wjg.v24.i38.4311] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/11/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.
Collapse
Affiliation(s)
- Elda Righi
- Department of Infectious Diseases, Santa Maria della Misericordia University Hospital, Udine 33100, Italy
| |
Collapse
|
33
|
Sena Corrales G, Perez Medina MI, Costo Muriel C, Reguera Iglesias JM. Cryptococcus neoformans peritonitis in the cirrhotic patient. Enferm Infecc Microbiol Clin 2018; 36:456-457. [PMID: 29183801 DOI: 10.1016/j.eimc.2017.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/06/2017] [Accepted: 10/10/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Gabriel Sena Corrales
- Fundación de Investigación Biomédica de Málaga (FIMABIS), Servicio de Enfermedades Infecciosas, Hospital Regional de Málaga Carlos Haya, Málaga, España.
| | | | - Clara Costo Muriel
- Servicio de Medicina Interna, Hospital Regional de Málaga Carlos Haya, Málaga, España
| | - Jose María Reguera Iglesias
- Fundación de Investigación Biomédica de Málaga (FIMABIS), Servicio de Enfermedades Infecciosas, Hospital Regional de Málaga Carlos Haya, Málaga, España
| |
Collapse
|
34
|
Sofjan AK, Musgrove RJ, Beyda ND, Russo HP, Lasco TM, Yau R, Restrepo A, Garey KW. Prevalence and predictors of spontaneous bacterial peritonitis due to ceftriaxone-resistant organisms at a large tertiary centre in the USA. J Glob Antimicrob Resist 2018; 15:41-47. [PMID: 29842975 DOI: 10.1016/j.jgar.2018.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/03/2018] [Accepted: 05/21/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The epidemiology of spontaneous bacterial peritonitis (SBP) due to ceftriaxone-resistant organisms has not been well studied in the USA. The primary objective of this study was to assess the prevalence and predictors of ceftriaxone-resistant SBP at a large US tertiary-care centre. METHODS This 1:1:4 case-case-control study included 141 adults with liver cirrhosis admitted from November 2011 to March 2016. Case group 1 were patients with SBP with a ceftriaxone-resistant organism (n=21). Case group 2 were patients with SBP with a ceftriaxone-susceptible organism (n=26). The control group were patients without SBP (n=94). Multiple logistic regression analysis was used to identify predictors of ceftriaxone-resistant SBP. RESULTS Fifty isolates were identified from 47 patients with culture-positive SBP (case groups 1 and 2). Of these 50 isolates, 32 (64%) were Gram-negatives [mostly Enterobacteriaceae (91%)], 15 (30%) were Gram-positives and 3 (6%) were Candida spp. The prevalence of ceftriaxone resistance in patients with culture-positive SBP was 45% (21/47). The most common ceftriaxone-resistant organisms were ESBL-producing Enterobacteriaceae (45%). Independent predictors of ceftriaxone-resistant SBP included duration of β-lactam therapy in the past 90days (aOR=1.07, 95% CI 1.01-1.13) and recent invasive gastrointestinal procedure (aOR=12.47, 95% CI 2.74-56.67). CONCLUSIONS The prevalence of ceftriaxone-resistant SBP was significant at a US tertiary centre. Local epidemiological data and identification of risk factors associated with ceftriaxone-resistant SBP, e.g. increased usage of previous β-lactam therapy and invasive gastrointestinal procedure, may help clinicians identify patients requiring alternative empirical antibiotics.
Collapse
Affiliation(s)
- Amelia K Sofjan
- Department of Pharmacy Practice and Translational Research, Room 4025, University of Houston College of Pharmacy, 4849 Calhoun Road, Houston, TX 77204-5039, USA.
| | - Rachel J Musgrove
- Department of Pharmacy Practice and Translational Research, Room 4025, University of Houston College of Pharmacy, 4849 Calhoun Road, Houston, TX 77204-5039, USA
| | - Nicholas D Beyda
- Department of Pharmacy Practice and Translational Research, Room 4025, University of Houston College of Pharmacy, 4849 Calhoun Road, Houston, TX 77204-5039, USA
| | - Hannah P Russo
- Department of Pharmacy, CHI Baylor St Luke's Medical Center, 6720 Bertner Ave., Houston, TX, USA
| | - Todd M Lasco
- Department of Pharmacy, CHI Baylor St Luke's Medical Center, 6720 Bertner Ave., Houston, TX, USA
| | - Raymond Yau
- Department of Pharmacy, CHI Baylor St Luke's Medical Center, 6720 Bertner Ave., Houston, TX, USA
| | - Alejandro Restrepo
- Section of Infectious Diseases, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, Room 4025, University of Houston College of Pharmacy, 4849 Calhoun Road, Houston, TX 77204-5039, USA
| |
Collapse
|
35
|
Shizuma T. Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: A literature review. World J Hepatol 2018; 10:254-266. [PMID: 29527261 PMCID: PMC5838444 DOI: 10.4254/wjh.v10.i2.254] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/31/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial (SBP) and spontaneous fungal peritonitis (SFP) can be a life-threatening infection in patients with liver cirrhosis (LC) and ascites. One of the possible mechanisms of developing SBP is bacterial translocation. Although the number of polymorphonuclear cells in the culture of ascitic fluid is diagnostic for SBP, secondary bacterial peritonitis is necessary to exclude. The severity of underlying liver dysfunction is predictive of developing SBP; moreover, renal impairment and infections caused by multidrug-resistant (MDR) organism are associated with a fatal prognosis of SBP. SBP is treated by antimicrobials, but initial empirical treatment may not succeed because of the presence of MDR organisms, particularly in nosocomial infections. Antibiotic prophylaxis is recommended for patients with LC at a high risk of developing SBP, gastrointestinal bleeding, or a previous episode of SBP, but the increase in the risk of developing an infection caused by MDR organisms is a serious concern globally. Less is known about SFP in patients with LC, but the severity of underlying liver dysfunction may increase the hospital mortality. SFP mortality has been reported to be higher than that of SBP partially because the difficulty of early differentiation between SFP and SBP induces delayed antifungal therapy for SFP.
Collapse
Affiliation(s)
- Toru Shizuma
- Department of Physiology, Tokai University School of Medicine, Isehara 2591193, Japan
| |
Collapse
|
36
|
Abstract
Polymicrobial intra-abdominal infections (IAIs) are clinically prevalent and cause significant morbidity and mortality, especially those involving fungi. Our laboratory developed a mouse model of IAI and demonstrated that intraperitoneal inoculation with Candida albicans or other virulent non-albicans Candida (NAC) species plus Staphylococcus aureus resulted in 70 to 80% mortality in 48 to 72 h due to robust local and systemic inflammation (sepsis). Surprisingly, inoculation with Candida dubliniensis or Candida glabrata with S. aureus resulted in minimal mortality, and rechallenge of these mice with lethal C. albicans/S. aureus (i.e., coninfection) resulted in >90% protection. The purpose of this study was to define requirements for C. dubliniensis/S. aureus-mediated protection and interrogate the mechanism of the protective response. Protection was conferred by C. dubliniensis alone or by killed C. dubliniensis plus live S. aureus. S. aureus alone was not protective, and killed S. aureus compromised C. dubliniensis-induced protection. C. dubliniensis/S. aureus also protected against lethal challenge by NAC plus S. aureus and could protect for a long-term duration (60 days between primary challenge and C. albicans/S. aureus rechallenge). Unexpectedly, mice deficient in T and B cells (Rag-1 knockouts [KO]) survived both the initial C. dubliniensis/S. aureus challenge and the C. albicans/S. aureus rechallenge, indicating that adaptive immunity did not play a role. Similarly, mice depleted of macrophages prior to rechallenge were also protected. In contrast, protection was associated with high numbers of Gr-1hi polymorphonuclear leukocytes (PMNLs) in peritoneal lavage fluid within 4 h of rechallenge, and in vivo depletion of Gr-1+ cells prior to rechallenge abrogated protection. These results suggest that Candida species can induce protection against a lethal C. albicans/S. aureus IAI that is mediated by PMNLs and postulated to be a unique form of trained innate immunity. Polymicrobial intra-abdominal infections are clinically devastating infections with high mortality rates, particularly those involving fungal pathogens, including Candida species. Even in patients receiving aggressive antimicrobial therapy, mortality rates remain unacceptably high. There are no available vaccines against IAI, which is complicated by the polymicrobial nature of the infection. IAI leads to lethal systemic inflammation (sepsis), which is difficult to target pharmacologically, as components of the inflammatory response are also needed to control the infection. Our studies demonstrate that prior inoculation with low-virulence Candida species provides strong protection against subsequent lethal infection with C. albicans and S. aureus. Surprisingly, protection is long-lived but not mediated by adaptive (specific) immunity. Instead, protection is dependent on cells of the innate immune system (nonspecific immunity) and provides protection against other virulent Candida species. This discovery implies that a form of trained innate immunity may be clinically effective against polymicrobial IAI.
Collapse
|
37
|
Berinstein J, Likhitsup A, Vedula SC, Conjeevaram H. Cryptic but Deadly: A Serious Killer in Patients with Advanced Liver Disease that Should Not Be Missed. Cureus 2017; 9:e1976. [PMID: 29492365 PMCID: PMC5821507 DOI: 10.7759/cureus.1976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Cryptococcal peritonitis is an under-recognized disease that is an important cause of mortality in end-stage liver disease. We report a 43-year old male with decompensated cirrhosis secondary to refractory autoimmune hepatitis on immunosuppression with hepatocellular carcinoma who developed cryptococcal peritonitis. The patient subsequently developed ischemic bowel and multisystem organ failure secondary to abdominal compartment syndrome, leading to rapid deterioration and death. Frequently, these patients experience delays in diagnosis and treatment, which leads to a rapid and high mortality. This case report synthesizes data regarding the optimal approach for screening and managing patients with cryptococcal peritonitis and proposes a pathogenic mechanism of mortality with implications for improved treatment in the future.
Collapse
Affiliation(s)
| | - Alisa Likhitsup
- Division of Gastroenterology and Hepatology, University of Michigan
| | | | - Hari Conjeevaram
- Division of Gastroenterology and Hepatologoy, University of Michigan
| |
Collapse
|
38
|
Singh N, Sifri CD, Silveira FP, Miller R, Gregg KS, Huprikar S, Lease ED, Zimmer A, Dummer JS, Spak CW, Koval C, Banach DB, Shroff M, Le J, Ostrander D, Avery R, Eid A, Razonable RR, Montero J, Blumberg E, Alynbiawi A, Morris MI, Randall HB, Alangaden G, Tessier J, Cacciarelli TV, Wagener MM, Sun HY. Unique characteristics of cryptococcosis identified after death in patients with liver cirrhosis: comparison with concurrent cohort diagnosed antemortem. Med Mycol 2017; 55:278-284. [PMID: 27601609 DOI: 10.1093/mmy/myw079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/21/2016] [Indexed: 11/13/2022] Open
Abstract
Characteristics of cirrhosis-associated cryptococcosis first diagnosed after death are not fully known. In a multicenter study, data generated as standard of care was systematically collected in 113 consecutive patients with cirrhosis and cryptococcosis followed for 80 patient-years. The diagnosis of cryptococcosis was first established after death in 15.9% (18/113) of the patients. Compared to cases diagnosed while alive, these patients had higher MELD score (33 vs. 22, P = .029) and higher rate of cryptococcemia (75.0% vs. 41.9%, P = .027). Cases diagnosed after death, in comparison to those diagnosed during life were more likely to present with shock (OR 3.42, 95% CI 1.18-9.90, P = .023), require mechanical ventilation at admission (OR 8.5, 95% CI 2.74-26.38, P = .001), less likely to undergo testing for serum cryptococcal antigen (OR 0.07, 95% CI 0.02-0.21, P < .001) and have positive antigen when the test was performed (OR 0.07, 95% CI 0.01-0.60, P = .016). In a subset of cirrhotic patients with advanced liver disease cryptococcosis was first recognized after death. These patients had the characteristics of presenting with fulminant fungemia, were less likely to have positive serum cryptococcal antigen and posed a diagnostic challenge for care providers.
Collapse
Affiliation(s)
- Nina Singh
- University of Pittsburgh, Pittsburgh, PA
| | | | | | - Rachel Miller
- University of Iowa, Iowa City, IA; Duke University Medical Center, Durham, NC
| | | | | | | | | | | | | | | | - David B Banach
- Yale School of Medicine, New Haven, CT; University of Connecticut School of Medicine, Farmington, CT
| | - Miloni Shroff
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Jade Le
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Hsin Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
39
|
Abstract
INTRODUCTION AND AIM 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. PATIENTS AND METHODS 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. RESULTS 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. CONCLUSION 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.
Collapse
|
40
|
Mayr U, Rasch S, Schmid RM, Huber W, Lahmer T. First description of spontaneous fungal peritonitis caused by Fusarium solani in a critically ill patient with liver cirrhosis. New Microbes New Infect 2017; 20:16-17. [PMID: 28948024 PMCID: PMC5601303 DOI: 10.1016/j.nmni.2017.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/02/2017] [Accepted: 08/07/2017] [Indexed: 11/17/2022] Open
Abstract
Fusarium spp., common soil moulds, are emerging fungal pathogens in immunocompromised subjects. We report the first case of Fusarium solani peritonitis in a patient with liver cirrhosis. Because of the high morbidity and mortality associated with fusariosis, an aggressive approach to treatment as well as identification of the species and drug susceptibilities is warranted.
Collapse
Affiliation(s)
- U Mayr
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - S Rasch
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - R M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - W Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - T Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| |
Collapse
|
41
|
Yang AM, Inamine T, Hochrath K, Chen P, Wang L, Llorente C, Bluemel S, Hartmann P, Xu J, Koyama Y, Kisseleva T, Torralba MG, Moncera K, Beeri K, Chen CS, Freese K, Hellerbrand C, Lee SM, Hoffman HM, Mehal WZ, Garcia-Tsao G, Mutlu EA, Keshavarzian A, Brown GD, Ho SB, Bataller R, Stärkel P, Fouts DE, Schnabl B. Intestinal fungi contribute to development of alcoholic liver disease. J Clin Invest 2017; 127:2829-2841. [PMID: 28530644 DOI: 10.1172/jci90562] [Citation(s) in RCA: 319] [Impact Index Per Article: 45.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/30/2017] [Indexed: 12/14/2022] Open
Abstract
Chronic liver disease with cirrhosis is the 12th leading cause of death in the United States, and alcoholic liver disease accounts for approximately half of all cirrhosis deaths. Chronic alcohol consumption is associated with intestinal bacterial dysbiosis, yet we understand little about the contribution of intestinal fungi, or mycobiota, to alcoholic liver disease. Here we have demonstrated that chronic alcohol administration increases mycobiota populations and translocation of fungal β-glucan into systemic circulation in mice. Treating mice with antifungal agents reduced intestinal fungal overgrowth, decreased β-glucan translocation, and ameliorated ethanol-induced liver disease. Using bone marrow chimeric mice, we found that β-glucan induces liver inflammation via the C-type lectin-like receptor CLEC7A on Kupffer cells and possibly other bone marrow-derived cells. Subsequent increases in IL-1β expression and secretion contributed to hepatocyte damage and promoted development of ethanol-induced liver disease. We observed that alcohol-dependent patients displayed reduced intestinal fungal diversity and Candida overgrowth. Compared with healthy individuals and patients with non-alcohol-related cirrhosis, alcoholic cirrhosis patients had increased systemic exposure and immune response to mycobiota. Moreover, the levels of extraintestinal exposure and immune response correlated with mortality. Thus, chronic alcohol consumption is associated with an altered mycobiota and translocation of fungal products. Manipulating the intestinal mycobiome might be an effective strategy for attenuating alcohol-related liver disease.
Collapse
Affiliation(s)
- An-Ming Yang
- Department of Medicine, UCSD, La Jolla, California, USA.,Department of Internal Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Tatsuo Inamine
- Department of Medicine, UCSD, La Jolla, California, USA.,Department of Pharmacotherapeutics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | | | - Peng Chen
- Department of Medicine, UCSD, La Jolla, California, USA
| | - Lirui Wang
- Department of Medicine, UCSD, La Jolla, California, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, California, USA
| | - Cristina Llorente
- Department of Medicine, UCSD, La Jolla, California, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, California, USA
| | - Sena Bluemel
- Department of Medicine, UCSD, La Jolla, California, USA
| | | | - Jun Xu
- Department of Surgery, UCSD, La Jolla, California, USA
| | | | | | | | | | - Karen Beeri
- J. Craig Venter Institute, La Jolla, California, USA
| | - Chien-Sheng Chen
- Institute of Systems Biology and Bioinformatics, National Central University, Taoyuan City, Taiwan
| | - Kim Freese
- Institute of Biochemistry (Emil-Fischer Zentrum), Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Claus Hellerbrand
- Institute of Biochemistry (Emil-Fischer Zentrum), Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Serene Ml Lee
- Department of General, Visceral and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Hal M Hoffman
- Department of Medicine, UCSD, La Jolla, California, USA.,Department of Pediatrics, UCSD, La Jolla, California, USA
| | - Wajahat Z Mehal
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA.,Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA.,Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ece A Mutlu
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Ali Keshavarzian
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Gordon D Brown
- Aberdeen Fungal Group, Medical Research Council Centre for Medical Mycology, University of Aberdeen, Aberdeen, United Kingdom
| | - Samuel B Ho
- Department of Medicine, UCSD, La Jolla, California, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, California, USA
| | - Ramon Bataller
- Liver Center, Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Peter Stärkel
- Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | | | - Bernd Schnabl
- Department of Medicine, UCSD, La Jolla, California, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, California, USA
| |
Collapse
|
42
|
Invasive Candida Infections in Liver Transplant Recipients: Clinical Features and Risk Factors for Mortality. Transplant Direct 2017; 3:e156. [PMID: 28573191 PMCID: PMC5441987 DOI: 10.1097/txd.0000000000000673] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/18/2017] [Indexed: 12/18/2022] Open
Abstract
Supplemental digital content is available in the text. Background Invasive fungal infections remain a leading cause of morbidity and mortality among liver transplant recipients (LTRs). In this patient population, invasive Candida infections (ICIs) account for the large majority of cases. To date, only small studies and case-series analysing clinical presentation and risk factors for mortality in LTRs with ICIs are available. Methods We performed a retrospective multicenter multinational study in 10 centers in Europe and Brazil. All consecutive LTRs developing ICIs during the period January 2011 to December 2013 were included in the study. Results A total of 42 LTRs were included. Median age was 52.5 years, and 78.6% of patients were men. Viral hepatitis was the most common cause for liver transplantation (42.9%). Candidemia represented the majority of cases (24, 57.1%), followed by intra-abdominal candidiasis (18, 42.9%). Overall 30-day mortality was 23.8%, with higher mortality in patients with candidemia compared with intra-abdominal candidiasis (37.5% vs 5.6%, P = 0.02). Multivariate analysis showed candidemia to be a risk factor associated with mortality among LTRs presenting ICIs (odds ratio, 11.86; 95% confidence interval, 1.5-280; P = 0.01). Candida albicans represented the most common isolate (59.5%). High rates of antifungal resistances were found, with 16.7% and 4.8% of isolates displaying resistance to azoles and caspofungin, respectively. Conclusions Our study confirms the occurrence of high mortality rates in LTRs developing ICIs. Mortality rates varied according to the type of infection, with candidemia representing a risk factor for mortality. The high rates of antifungal resistance should be considered in the choice of the empiric antifungal regimen.
Collapse
|
43
|
Abstract
Purpose of the review Cryptococcal disease is most often thought of in the context of HIV infection. Much of our knowledge of the disease originates from its management in the HIV-positive population over the last 30 years. While the majority of cases globally continue to occur in the setting of advanced HIV, Cryptococcus species is increasingly responsible for disease in HIV-negative populations including those considered normal hosts and these HIV-negative populations will be the focus of this review. Recent findings Currently available data indicated that significant differences exist in epidemiology, clinical presentation, management and outcomes of cryptococcal disease in HIV-negative populations when compared to those living with HIV. Summary Further research is required to improve our knowledge of cryptococcal disease in particular in HIV-negative cohorts so as to optimise management of the disease in the future.
Collapse
|
44
|
Abstract
Spontaneous fungal peritonitis (SFP) is an infrequent but severe complication most commonly described in patients with liver cirrhosis. We present the first case of culture-proven SFP occurring in cardiogenic ascites. The diagnosis of SFP was clinically challenging as the initial ascites was consistent with the more common diagnosis of spontaneous bacterial peritonitis (SBP). The patient did not respond to antibacterial therapy, however, and the final diagnosis was only made with positive ascitic cultures that grew Candida glabrata. SFP should be considered in patients with either cardiac or cirrhotic ascites and have a delayed or lack of response to traditional SBP treatment.
Collapse
|
45
|
Bassetti M, Peghin M, Carnelutti A, Righi E, Merelli M, Ansaldi F, Trucchi C, Alicino C, Sartor A, Toniutto P, Wauters J, Laleman W, Tascini C, Menichetti F, Luzzati R, Brugnaro P, Mesini A, Raviolo S, De Rosa FG, Lagunes L, Rello J, Dimopoulos G, Colombo AL, Nucci M, Vena A, Bouza E, Muñoz P, Tumbarello M, Losito R, Martin-Loeches I, Viscoli C. Clinical characteristics and predictors of mortality in cirrhotic patients with candidemia and intra-abdominal candidiasis: a multicenter study. Intensive Care Med 2017; 43:509-518. [DOI: 10.1007/s00134-017-4717-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/07/2017] [Indexed: 12/23/2022]
|
46
|
Majeed A, Ullah W, Zahid U, Al Mohajer M. Persistent spontaneous fungal peritonitis secondary to Candida albicans in a patient with alcoholic cirrhosis and review of the literature. BMJ Case Rep 2016; 2016:bcr-2016-216979. [PMID: 27873750 DOI: 10.1136/bcr-2016-216979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Candida albicans is a common human pathogen. Occasionally, it can cause peritonitis in immunocompromised and postsurgical patients. We report a case of a male patient who presented with abdominal pain and distention. He had a history of end-stage liver disease secondary to alcoholism. His peritoneal fluid culture revealed C albicans, and (1-3)-β-d glucan (BDG) level was elevated. His hospital course was complicated by sepsis and renal failure. He was treated with antifungals for spontaneous fungal peritonitis. Fungal peritonitis should be suspected in patients with chronic liver disease particularly with elevated BDG levels.
Collapse
Affiliation(s)
- Aneela Majeed
- Division of Infectious Disease, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Waqas Ullah
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Umar Zahid
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Mayar Al Mohajer
- Division of Infectious Disease, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| |
Collapse
|
47
|
García-Rodríguez J, Quiles-Melero MI. Peritonitis fúngica primaria: una asignatura pendiente. Enferm Infecc Microbiol Clin 2016; 34:469-70. [DOI: 10.1016/j.eimc.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/18/2016] [Indexed: 11/30/2022]
|
48
|
Fiore M, Leone S. Spontaneous fungal peritonitis: Epidemiology, current evidence and future prospective. World J Gastroenterol 2016; 22:7742-7747. [PMID: 27678356 PMCID: PMC5016373 DOI: 10.3748/wjg.v22.i34.7742] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 06/30/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial peritonitis is a complication of ascitic patients with end-stage liver disease (ESLD); spontaneous fungal peritonitis (SFP) is a complication of ESLD less known and described. ESLD is associated to immunodepression and the resulting increased susceptibility to infections. Recent perspectives of the management of the critically ill patient with ESLD do not specify the rate of isolation of fungi in critically ill patients, not even the antifungals used for the prophylaxis, neither optimal treatment. We reviewed, in order to focus the epidemiology, characteristics, and, considering the high mortality rate of SFP, the use of optimal empirical antifungal therapy the current literature.
Collapse
|
49
|
Lahmer T, Brandl A, Rasch S, Schmid RM, Huber W. Fungal Peritonitis: Underestimated Disease in Critically Ill Patients with Liver Cirrhosis and Spontaneous Peritonitis. PLoS One 2016; 11:e0158389. [PMID: 27390856 PMCID: PMC4938562 DOI: 10.1371/journal.pone.0158389] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 05/10/2016] [Indexed: 12/18/2022] Open
Abstract
Introduction Spontaneous peritonitis, especially spontaneous fungal peritonitis (SFP), is an important and potentially fatal complication in patients with endstage liver disaese. We evaluated potential risk factors, microbiological findings, and outcome of patients with SFP compared to spontaneous bacterial peritonitis (SBP) in critically ill patients. Methods Retrospective analyses of critically ill patients with suspected spontaneous peritonitis. Results Out of 205 patients, 20 (10%) had SFP, 28 (14%) had SBP, 48 (24%) had peritonitis without microbiological findings (SP) and 109 (52%) had no-peritonitis (NP). APACHE II and SOFA score were significantly higher in patients with SFP (26; 22–28; p<0.004 and 16; 14–18; p<0.002), SBP (26; 22–28; p<0.004 and 16; 14–18; p<0.002) and SP (24; 18–30; p<0.045 and 14; 10–18; p<0.044) as compared to NP (22; 16–24 and 12; 10–14). CHILD Pugh classification was mainly CHILD C and MELD Score was in patients with SFP (34; 18–40; p<0.001), SBP (32;12–40 p<0.002) and SP (29; 14–40 p<0.003) significantly higher as compared to NP (25;8–40). Nosocomial peritonitis could be significantly more often found in patients with SFP (65%; p<0.023) and SBP (62%, p<0.030) as compared to SP (51 p = 0.243) and NP (45%). Antibiotic pretreatment last 3 month prior peritonitis was significantly more often in patients with SFP (85%; p<0.002), SBP (71%, p<0.033), and SP (56; p<0.040) as compared to NP (33%). Candida albicans (60%; 12/20) was the most common isolated fungus, followed by Candida glabrata (13%) and Candida krusei (13%). Mortality rate was significantly higher in patients with SFP (90%, p<0.001), followed by SBP (75%; p<0.001) and SP (69%; p<0.001) as compared to NP (45%). Conclusion SFP is not a rare complication in end stage liver disease which is associated with increased mortality. Physicians should be aware of SFP in patients with CHILD C liver cirrhosis, elevated MELD score, antibiotic pretreatment and nosocomial peritonitis.
Collapse
Affiliation(s)
- Tobias Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
- * E-mail:
| | - Andreas Brandl
- Department of General, Visceral and Transplantation Surgery and Department of General, Visceral, Vascular and Thoracic Surgery, Campus Virchow and Mitte, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Rasch
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Roland M. Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| |
Collapse
|
50
|
A 72-Year-Old End-Stage Liver Disease Patient With Lethargy. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2016. [DOI: 10.1097/ipc.0000000000000405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|