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

Strategies to Prevent Infections in Dialysis Patients

Infections are the second leading cause of death among patients with end-stage kidney disease, behind only cardiovascular disease. In addition, patients on chronic dialysis are at a higher risk for acquiring infection caused by multidrug-resistant organisms and for death resulting from infection owing to their likelihood of requiring treatment that involves invasive devices, their frequent exposure to antibiotics, and their impaired immunity. Vascular access is a major risk factor for bacteremia, hospitalization, and mortality among hemodialysis (HD) patients. Catheter-related bacteremia is the most severe central venous catheter (CVC)-related infection and increases linearly with the duration of catheter use. Given the high prevalence of CVC use and its direct association with catheter-related bacteremia, which adversely impacts morbidity and mortality rates among HD patients, several prevention measures aimed at reducing the rates of CVC-related infection have been proposed and implemented. As a result, a large number of clinical trials, systematic reviews, and meta-analyses have been conducted to assess the effectiveness, clinical applicability, and long-term adverse effects of such measures. Peritoneal dialysis chronic treatment without the occurence of peritonitis is rare. Although most cases of peritonitis can be treated adequately with antibiotics, some cases are complicated by hospitalization or a temporary or permanent need to abstain from using the peritoneal dialysis catheter. Severe and long-lasting peritonitis can lead to peritoneal membrane failure, requiring the treatment method to be switched to HD. Some measures as patients training, early diagnosis, and choice of antibiotics can contribute to the successful treatment of peritonitis. Finally, medical directors are key leaders in infection prevention and are an important resource to implement programs to monitor and improve infection prevention practices at all levels within the dialysis clinic.

Clinical, Epidemiological and Laboratory Features of Invasive Candida parapsilosis Complex Infections in a Brazilian Pediatric Reference Hospital during the COVID-19 Pandemic

The present study aimed to describe the clinical, epidemiological and laboratory characteristics of invasive candidiasis by C. parapsilosis complex (CPC) in a Brazilian tertiary pediatric hospital during the COVID-19 pandemic. Clinical samples were processed in the BACT/ALERT® 3D system or on agar plates. Definitive identification was achieved by MALDI-TOF MS. Antifungal susceptibility was initially analyzed by the VITEK 2 system (AST-YS08 card) and confirmed by the CLSI protocol. Patient data were collected from the medical records using a structured questionnaire. CPC was recovered from 124 patients over an 18-month period, as follows: C. parapsilosis (83.87%), C. orthopsilosis (13.71%) and C. metapsilosis (2.42%). Antifungal resistance was not detected. The age of the patients with invasive CPC infections ranged from <1 to 18 years, and most of them came from oncology-related sectors, as these patients were more affected by C. parapsilosis. C. orthopsilosis infections were significantly more prevalent in patients from critical care units. Invasive infections caused by different pathogens occurred in 75 patients up to 30 days after the recovery of CPC isolates. Overall, 23 (18.55%) patients died within 30 days of CPC diagnosis. Catheter removal and antifungal therapy were important measures to prevent mortality. COVID-19 coinfection was only detected in one patient.

Peritonitis caused by paracoccidioides spp. in a patient on continuous ambulatory peritoneal dialysis - A case report

Paracoccidioidomycosis is a systemic mycosis found mainly in South America and is the most prevalent endemic and systemic mycosis in Brazil. The purpose of this paper was to report the case of a male patient who developed peritonitis caused by Paracoccidioides spp. Forty-eight-year-old, male patient, with type I Diabetes mellitus and chronic kidney disease who was undergoing a Continuous Ambulatory Peritoneal Dialysis (CAPD) program. After eighteen months of peritoneal dialysis, the patient developed turbidity of the peritoneal fluid and was diagnosed with peritonitis. Direct mycological examination of the peritoneal fluid revealed yeasts with morphology suggestive of Paracoccidioides spp. The patient was treated with sulfamethoxazole-trimethoprim (1,600 mg/320 mg dose/day) for 61 days, but he died because a bacterial septic shock. The diagnosis of opportunistic PCM peritonitis was later confirmed by autopsy and Paracoccidioides spp. isolation. This is the first reported case of a patient on CAPD who experienced complications due peritonitis caused by opportunistic PCM.

Autophagy in peritoneal fibrosis

Peritoneal dialysis (PD) is a widely accepted renal replacement therapy for patients with end-stage renal disease (ESRD). Morphological and functional changes occur in the peritoneal membranes (PMs) of patients undergoing long-term PD. Peritoneal fibrosis (PF) is a common PD-related complication that ultimately leads to PM injury and peritoneal ultrafiltration failure. Autophagy is a cellular process of "self-eating" wherein damaged organelles, protein aggregates, and pathogenic microbes are degraded to maintain intracellular environment homeostasis and cell survival. Growing evidence shows that autophagy is involved in fibrosis progression, including renal fibrosis and hepatic fibrosis, in various organs. Multiple risk factors, including high-glucose peritoneal dialysis solution (HGPDS), stimulate the activation of autophagy, which participates in PF progression, in human peritoneal mesothelial cells (HPMCs). Nevertheless, the underlying roles and mechanisms of autophagy in PF progression remain unclear. In this review, we discuss the key roles and potential mechanisms of autophagy in PF to offer novel perspectives on future therapy strategies for PF and their limitations.

Gut-derived fungemia due to Kodamaea ohmeri combined with invasive pulmonary aspergillosis: a case report

BACKGROUND

Kodamaea ohmeri is a rare pathogen with high mortality and is found among blood samples in a considerable proportion; however, gastrointestinal infection of K. ohmeri is extremely rare. Invasive pulmonary aspergillosis is also an uncommon fungal; these two fungal infections reported concomitantly are unprecedented.

CASE PRESENTATION

We described a case of a 37-year-old male who got infected with K. ohmeri and invasive pulmonary aspergillosis. We used the mass spectrometry and histopathology to identify these two fungal infections separately. For the treatment of K. ohmeri, we chose caspofungin. As for invasive pulmonary aspergillosis, we used voriconazole, amphotericin B, and then surgery. The patient was treated successfully through the collaboration of multiple disciplines.

CONCLUSIONS

We speculate that the destruction of the intestinal mucosa barrier can make the intestine one of the ways for certain fungi to infect the human body.

Meyerozyma guilliermondii species complex: review of current epidemiology, antifungal resistance, and mechanisms

Meyerozyma guilliermondii has been accepted as a complex composed of Meyerozyma guilliermondii, Meyerozyma carpophila, and Meyerozyma caribbica. M. guilliermondii is a saprophyte detected on human mucosa and skin. It can lead to serious infections in patients with risk factors like chemotherapy, immunodeficiency, gastrointestinal or cardiovascular surgery, and oncology disorders. Most deaths related to M. guilliermondii infections occur in individuals with malignancy. In recent decades, incidence of M. guilliermondii infections is increased. Sensitivity of this microorganism to conventional antifungals (e.g., amphotericin B, fluconazole, micafungin and anidulafungin) was reduced. Prophylactic and empirical uses of these drugs are linked to elevated minimal inhibitory concentrations (MICs) of M. guilliermondii. Drug resistance has concerned many researchers across the world. They are attempting to discover appropriate solution to combat this challenge. This study reviews the most important mechanisms of resistance to antifungals developed by in M. guilliermondii species complex.

Card9 protects fungal peritonitis through regulating Malt1-mediated activation of autophagy in macrophage

Fungal peritonitis is an inflammatory condition of the peritoneum which occurs secondary to peritoneal dialysis. Most cases of peritonitis are caused by microbial invasion into the peritoneal cavity, resulting in high morbidity and mortality. Unlike bacterial peritonitis, little is known on fungal peritonitis. Card9, an adapter protein, plays a critical role in anti-fungal immunity. In this study, by using zymosan-induced peritonitis and C. albicans-induced peritonitis mouse model, we demonstrated that fungal peritonitis was exacerbated in Card9^-/- mice, compared with WT mice. Next, we found the autophagy activation of peritonealmacrophages was impaired in Card9^-/- peritonitis mice. The autophagy agonist, MG132, ameliorated peritonitis in Card9^-/- mice. The result of microarray analysis indicates Malt1 was significantly decreased in Card9^-/- peritonitis mice. Furthermore, we demonstrated that Malt1 interacts with P62 and mediates the function of P62 to clear ubiquitinated proteins. After overexpression of Malt1, impaired autophagy activation caused by Card9 deficient was significantly rescued. Together, our results indicate that Card9 protects fungal peritonitis by regulating Malt1-mediated autophagy in macrophages. Our research provides a new idea for the pathogenesis of fungal peritonitis, which is of great significance for the clinical treatment of fungal peritonitis.

Microbiology and Outcome of Peritoneal Dialysis-Related Peritonitis in Elderly Patients: A Retrospective Study in China

Objective

The number of elderly patients on peritoneal dialysis (PD) has rapidly increased in the past few decades. We sought to explore the microbiology and outcomes of peritonitis in elderly PD patients compared with younger PD patients.

Methods

We conducted a retrospective study to analyze the clinical characteristics, causative organism distribution, and outcome of all PD patients who developed peritonitis between September 1, 2014 and December 31, 2020, from Second Xiangya Hospital, Central South University, China. Patients who experienced peritonitis were separated into elderly and younger groups. The elderly was defined as ≥ 65 years old at the initiation of PD.

Results

Among 1,200 patients, 64(33.9%) in elderly (n = 189) and 215 (21.3%) in younger (n = 1,011) developed at least one episode of peritonitis. A total of 394 episodes of peritonitis occurred in 279 patients. Of these, 88 episodes occurred in 64 elderly patients, and 306 episodes occurred in 215 younger patients. Gram-positive bacteria were the main causative organisms in elderly and younger patients (43.2% and 38.0%, respectively). Staphylococcus and Escherichia coli were the most common gram-positive and gram-negative bacteria, respectively. Fungal peritonitis in elderly patients was higher compared with younger patients (χ2 = 6.55, P = 0.01). Moreover, Acinetobacter baumannii (χ ²=9.25, P = 0.002) and polymicrobial peritonitis (χ ² = 6.41, P = 0.01) in elderly patients were also significantly higher than that in younger patients. Additionally, elderly PD patients had higher peritonitis-related mortality than younger patients (χ ² = 12.521, P = 0.000), though there was no significant difference in catheter removal between the two groups. Kaplan-Meier analysis showed that cumulative survival was significantly lower in elderly patients than younger patients (log rank = 7.867, p = 0.005), but similar technical survival in both groups (log rank = 0.036, p = 0.849).

Conclusions

This retrospective study demonstrated that elderly PD patients were more likely to develop Acinetobacter baumannii, fungal and polymicrobial peritonitis than younger PD patients. In addition, peritonitis-related mortality was significantly higher in elderly patients, whereas peritonitis-related catheter removal was comparable between elderly and younger PD patients. Understanding microbiology and outcome in elderly patients will help to reduce the incidence of PD-associated peritonitis and improve the quality of life.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

Characteristics Analysis, Clinical Outcome and Risk Factors for Fungal Peritonitis in Peritoneal Dialysis Patients: A 10-Year Case-Control Study

Background: Fungal peritonitis (FP) is a rare but severe complication that can appear in patients receiving peritoneal dialysis (PD). This study aimed to investigate the incidence rate and clinical characteristics of FP, evaluate clinical outcomes between FP and bacterial peritonitis (BP) patients on PD, and especially estimate the risk factors for FP outbreak.

Methods: All episodes of FP diagnosed in our hospital from January 1, 2011, to December 31, 2020, were reviewed in this single-center study. FP cases were analyzed and compared with patients diagnosed with BP in a 1:6 ratio matching for case-control study. Patient information, including clinical information, biochemical analysis, and outcomes, was recorded. Univariate and multivariate logistic regression model were used to analyze the risk factors for FP.

Results: A total of 15 FP episodes were observed in 15 PD patients, with an FP rate of 0.0071 episodes per patient-year. Seventeen strains of fungi were isolated and identified. Candida was the most common pathogen (15 strains, 88.2%), followed by Aspergillus fumigatus (2 strains, 11.8%). Between the groups, FP group showed a higher rate of HD transfer and catheter removal, and a lower rate of PD resumption in the short-term outcome (all P < 0.01), while no significant difference in the mortality was noted during the whole study period. The multivariate logistic regression analysis showed that longer PD duration (odds ratio [OR] 1.042, 95% confidence interval [CI] 1.012–1.073, P < 0.01), higher serum potassium (OR 3.373, 95% CI 1.068–10.649, P < 0.05), elevated estimated glomerular filtration rate (eGFR) (OR 1.845, 95% CI 1.151–2.955, P < 0.05), reduced serum albumin level (OR 0.820, 95% CI 0.695–0.968, P < 0.05) and peritoneal effluent polymorphonuclear (PMN) count (OR 0.940, 95%CI 0.900–0.981, P < 0.01) were significantly increased the risk for FP.

Conclusion: These results suggested that FP leads to higher rate of catheter removal and HD transfer, and a lower rate of PD resumption than BP, and that additional attention should be paid to hypoalbuminemia, increased serum potassium, long PD duration, and low peritoneal effluent PMN in PD patients.

Kodamaea ohmeri as an Emerging Human Pathogen: A Review and Update

Background: Kodamaea ohmeri, previously known as Pichia ohmeri or Yamadazyma ohmeri, has been regarded as an emerging human pathogen in recent decades, and has caused various types of infections with high mortality. This study systematically reviewed all the published cases of K. ohmeri infection, aiming to have a better understanding of the clinical and epidemiological characteristics of the organism. Methods: All the published literature (as of March 31, 2021) on K. ohmeri, in four databases: PubMed, Embase, Web of Science, and CNKI, were systematically reviewed to select appropriate studies for summarizing the demographic information, clinical and microbiological characteristics of relevant infections. Results: A total of 51 studies involving 67 patients were included for final analysis, including 49 sporadic cases and two clusters of outbreaks. Neonates and the elderly constituted the majority of patients, and fungemia was the dominant infection type. Comorbidities (like malignancy, diabetes, and rheumatism), invasive operations, previous antibiotic use and prematurity, were commonly described in patients. Gene sequencing and broth microdilution method, were the most reliable way for the identification and antifungal susceptibility testing of K. ohmeri, respectively. Amphotericin B and fluconazole were the commonest antifungal therapies administered. The calculated mortality rates for K. ohmeri infection was higher than that of common candidemia. Conclusion: In this study, we systematically reviewed the epidemiology, clinical characteristics, microbiological features, treatment, and outcomes, of all the published cases on K. ohmeri. Early recognition and increased awareness of K. ohmeri as an emerging human pathogen by clinicians and microbiologists is important for effective management of this organism.

Along came a spider: an unusual organism identified in a peritoneal dialysis patient, a case report and literature review

Background

Peritoneal dialysis-associated peritonitis can uncommonly be caused by fungal infections. When they do present, they are associated with significant mortality and morbidity. We describe a case where a sample of peritoneal dialysate fluid grew Rhodotorula muciliginosa, a yeast organism present in the normal environment which has previously been reported as rarely causing peritonitis. We believe this is the first case where the Rhodotorula spp. and its origin has been identified.

Case presentation

A 20 year old male grew Rhodotorula muciliginosa from his peritoneal dialysis fluid on three separate occasions when a fluid sample was sent following a disconnection and subsequent set change. He was not systemically unwell and his peritoneal dialysate was clear. As Rhodotorula spp. is exceedingly difficult to treat our patient had his Tenchkoff catheter removed. Subsequent samples of soil and sand from his bearded dragon and Chilean tarantula cases, kept in his bedroom where dialysis occurred, were tested. The tarantula sand was identified as the source of the Rhodotorula spp. Of note, Candida was isolated from sand from the bearded dragon case. Once his Tenchkoff was removed he was treated with an intravenous course of antifungal therapy. He has since had a new Tenchkoff catheter inserted and recommenced PD following education around pets and hygiene.

Conclusions

In this era where people are keeping increasingly rare and unusual wildlife in their homes, this case highlights the need for clinician and nursing staff awareness of a patient’s home environment and hobbies when they are undergoing peritoneal dialysis. Sand from our patient’s tarantula case grew the colonising organism but interestingly soil from his bearded dragon case also isolated candida. This can also cause difficult to treat peritonitis.

Kodamaea ohmeri infections in humans: A systematic review

BACKGROUND

Kodamaea ohmeri, previously known as Pichia ohmeri or Yamadazyma ohmeri, belongs to the Saccharomycetaceae family and the Ascomycetae class, is the telomorphic form of C guilliermondii var. membranaefaciens and is frequently mistaken for Candida, as they belong to the same family. It has been isolated from environmental sources, such as sand, pools, seawater and fruits, while the last decades it is recognised as a rare pathogen that causes life-threatening infections in humans. The purpose of this study was to systemically review all published cases of K ohmeri infections in the literature and describe the epidemiology, microbiology, antimicrobial susceptibility, treatment and outcomes of these infections in humans.

METHODS

Systematic review of PubMed (through 27th December 2019) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of K ohmeri infections.

RESULTS

A total of 35 studies, containing data of 44 patients, were included in the analysis. The most common K ohmeri infections were those of the bloodstream, infective endocarditis and onychomycosis. Previous antibiotic use, presence of a central venous catheter, parenteral nutrition and cancer were very common among patients. Mortality was high in the case of fungemias but low for other types of infections. Amphotericin B and fluconazole are the most common agents used for treatment, even though alarming MICs for fluconazole were noted.

CONCLUSIONS

This systematic review thoroughly describes infections by K ohmeri and provides information on their epidemiology, clinical presentation, microbiology, antibiotic resistance patterns, treatment and outcomes.

Metabolic function, trophic mode, organics degradation ability and influence factor of bacterial and fungal communities in chicken manure composting

The metabolic function and organic degradation behavior of bacterial and fungal communities were detected in 60 days composting of chicken manure and pumice by using Biolog tools, PICRUSt and FUNGuild. Fungal diversity increased from 57 OTUs in fresh chicken manure to 109 OTUs in high temperature stage, while bacterial diversity decreased from 86 OTUs to 44 OTUs after composting treatment. The carbohydrates degradation ability of bacterial community was enhanced in the high temperature stage. Fungal community had relatively higher degradation rates of carboxylic acids and amino acids in the maturation stage. Saprotroph was the main trophic mode of fungal community during the incubation process. The fungal animal pathogen decreased from 12.5% to 1.2% after composting treatment. Bacterial community composition and substrates degradation rate were mainly influenced by redox potential, pH and moisture, while temperature was the main environmental factor influencing on organic degradation of fungal community.

Virulence properties and sensitivity profile of Candida parapsilosis complex species and Kodamaea ohmeri isolates from onychomycosis of HIV/AIDS patients

Cutaneous fungal infections include onychomycosis, an infection of the nail that affects both healthy and immunocompromised patients. This study investigated the in vitro hydrolytic enzymes production, adhesion and biofilm formation capacity of Candida parapsilosis complex species and Kodamaea ohmeri isolates from onychomycoses of HIV/AIDS patients and also established the antifungal sensitivity profiles of these isolates. Onychomycosis in HIV/AIDS patients showed a high prevalence of emerging yeasts, among which C. parapsilosis complex species and K. ohmeri were the most frequent. Three C. parapsilosis sensu stricto and two C. orthopsilosis isolates were resistant to amphotericin B and 83% of isolates were resistant to terbinafine. All three different species evaluated were proteinase and hemolysin producers. All isolates adhered to stainless steel and siliconized latex surfaces, and carbohydrates intensified adhesion of all isolates. Isolates adhered to keratinous nail and 50% formed biofilms with strong intensity. In multispecies or polymicrobial biofilms, C. albicans and Staphylococcus aureus regulated the biofilm formation of the analyzed species, decreasing the number of their cells in biofilms. The isolation of emerging yeast species from onychomycosis which are great producers of hydrolytic enzymes and with high adhesion and biofilm formation capacity is a result that should be considered relevant in clinical practice. In addition, half of the isolates was resistant to at least one of the tested antifungals. Taken together these data corroborate the infectious capacity and viability of these isolates under favorable conditions.

Peritonitis by Exophiala dermatitidis in a pediatric patient

Fungal peritonitis is frequent on peritoneal dialysis, with rare cases by Exophiala dermatitidis. A 25-month-old female admitted to the pediatric ICU with acute renal failure was submitted to peritoneal dialysis. After 10 days patient presented fever. Peritoneal fluid culture showed yeast colonies molecularly identified as E. dermatitidis. Patient was treated with voriconazole and hemodialysis. The literature was reviewed. Disseminated infections are frequently fatal, but appropriate diagnose and therapeutic led to cure in this case.

An Azole-Resistant Candida parapsilosis Outbreak: Clonal Persistence in the Intensive Care Unit of a Brazilian Teaching Hospital

The incidence of candidemia by the Candida parapsilosis complex has increased considerably in recent decades, frequently related to use of indwelling intravascular catheters. The ability of this pathogen to colonize healthcare workers (HCW)' hands, and to form biofilm on medical devices has been associated with the occurrence of nosocomial outbreaks and high mortality rates. Fluconazole has been the leading antifungal drug for the treatment of invasive candidiasis in developing countries. However, azole-resistant C. parapsilosis isolates are emerging worldwide, including in Brazil. Few studies have correlated outbreak infections due to C. parapsilosis with virulence factors, such as biofilm production. We thus conducted a microbiological investigation of C. parapsilosis complex isolates from a Brazilian teaching hospital. Additionally, we identified a previously unrecognized outbreak caused by a persistent azole-resistant C. parapsilosis (sensu stricto) clone in the intensive care unit (ICU), correlating it with the main clinical data from the patients with invasive candidiasis. The molecular identification of the isolates was carried out by PCR-RFLP assay; antifungal susceptibility and biofilm formation were also evaluated. The genotyping of all C. parapsilosis (sensu stricto) was performed by microsatellite analysis and the presence of ERG11 mutations was assessed in the azole non-susceptible isolates. Fourteen C. parapsilosis (sensu stricto) isolates were recovered from patients with invasive candidiasis, eight being fluconazole and voriconazole-resistant, and two intermediate only to fluconazole (FLC). All non-susceptible isolates showed a similar pattern of biofilm formation with low biomass and metabolic activity. The A395T mutation in ERG11 was detected exclusively among the azole-resistant isolates. According to the microsatellite analysis, all azole non-susceptible isolates from the adult ICU were clustered together indicating the occurrence of an outbreak. Regarding clinical data, all patients infected by the clonal non-susceptible isolates and none of the patients infected by the susceptible isolates had been previously exposed to corticosteroids (p = 0.001), while the remaining characteristics showed no statistical significance. The current study revealed the persistence of an azole non-susceptible C. parapsilosis clone with low capacity to form biofilm over two years in the adult ICU. These results reinforce the need of epidemiological surveillance and monitoring antifungal susceptibility of C. parapsilosis isolates in hospital wards.

Fungal peritonitis in peritoneal dialysis: 5-year review from a North China center

PURPOSE

Fungal peritonitis (FP) is a rare but devastating complication in peritoneal dialysis (PD), accounting for high rates of technique failure, morbidity and mortality. This study was conducted to investigate FPs with regard to peritonitis rate, microbiology testing, patient characteristics, clinical features, antifungal treatments, and clinical outcomes in patients on PD.

METHODS

This single-center study retrospectively reviewed all FP episodes diagnosed from June 1, 2012 to June, 2017. All FPs were matched in a 1:5 ratio with PD patients diagnosed with bacterial peritonitis. Clinical, biochemical characteristics and detailed data on peritonitis episodes were recorded.

RESULTS

Eleven fungal peritonitis episodes (rate of 0.0067 episodes per patient-year on dialysis) were identified. All FPs were caused by Candida species (identification and antifungal susceptibility testing were performed with VITEK 2^® compact system), including C. albicans (6/11), C. parapsilosis (4/11) and C. krusei (1/11). Except C. krusei, no Candida resistance to fluconazole was detected. Compared to bacterial peritonitis (matched cases, n = 55), FP group showed higher rate of previous antibiotic use (p = 0.002), higher total effluent cell count (p = 0.007), and lower serum albumin (p = 0.01), higher rate of infection-related surgery (p < 0.001), HD transfer (p = 0.001), and all-cause death (p = 0.006). High prevalence (≥ 50%) of female gender, anuria, CCI ≥ 4, hypoalbuminemia, anemia, and hypokalemia were also observed in FP patients. More than half of the FP patients presented gastrointestinal symptoms (7/11) and extraperitoneal infection (6/11). Eight (72.7%) patients had catheter surgically removed with a median 5.5 lag days, four (36.4%) patients died within 3 months and six (54.5%) cases led to technique failure.

CONCLUSIONS

FP results in high rates of catheter loss and all-cause mortality in 3 months of follow-up, candida species were the commonest pathogens in our center. Variations of clinical features and susceptibility patterns were observed. Gastrointestinal disorders maybe a potential risk factor for FP.

Fungal peritonitis in peritoneal dialysis: a 34-year single centre evaluation

Backgound

Fungal peritonitis (FP) is one of the most important causes of peritoneal dialysis (PD) failure, often burdened by increased morbility and mortality. This study evaluates the clinical course of FP cases that arose between 1983 and 2016 in a single PD unit.

Methods

We conducted a retrospective observational analysis of FP episodes recorded in the Baxter POET (Peritonitis Organism Exit sites Tunnel infections) registry and clinical records. FP incidence rate, PD and patients’ survival and clinical characteristics of the study population were analysed, taking into account the evolution of clinical practice during the study period as a result of technical innovation, scientific evidence and guideline history.

Results

Fourteen FP cases (2.8%) were detected. The overall incidence of PD peritonitis was one episode/27 patient-months. Candida parapsilosis was the most frequently (50%) detected yeast. Seventy-five per cent of cases were considered secondary FP. This group experienced 2.6±1.7 bacterial peritonitis before FP, most frequently due to Staphylococcus and Enterococcus species. Most patients were treated with fluconazole for ≥8 days. All subjects were hospitalized for a median time of 25 days. Tenckhoff catheter removal occurred in all cases of FP and all patients were transferred to haemodialysis. Two patients died. From December 2010 to December 2016, no FP episodes were recorded.

Conclusions

FP is confirmed as a significant cause of PD drop out and increases patients’ mortality risk. Prompt diagnosis of FP, targeted antifugal therapy and rapid PD catheter removal are essential strategies for improved patient and PD survival.

Echinocandins for management of invasive candidiasis in patients with liver disease and liver transplantation

Candida species remains one of the most important causes of opportunistic infections worldwide. Invasive candidiasis (IC) is associated with considerable morbidity and mortality in liver disease (LD) patients if not treated promptly. Echinocandins are often recommended as a first-line empirical treatment for managing IC and can especially play a critical role in managing IC in LD patients. However, advanced LD patients are often immunocompromised and critically ill. Hence altered pharmacokinetics, drug interactions as well as tolerance issues of antifungal treatments are a concern in these patients. This comprehensive review examines the epidemiology, risk factors and diagnosis of IC in patients with LD and evaluates differences between three available echinocandins for treating this group of patients.

Intestinal perforation by a peritoneal dialysis catheter in which fungal peritonitis led to diagnosis: a rare case report

Intestinal perforation by a peritoneal catheter is an uncommon, but serious, complication that has a high mortality rate. Intestinal perforation in peritoneal dialysis (PD) patients is difficult to diagnose using symptoms and radiological findings, which may result in a delay in diagnosis. Moreover, intestinal perforation complicated with fungal peritonitis is reportedly a severe condition with a poor prognosis. Herein, we report the case of a 78-year-old man on PD, whose diagnosis of perforative peritonitis was difficult to diagnose preoperatively. He was transferred to our hospital complaining of relapsing PD-related peritonitis due to Klebsiella oxytoca infection 2 months after the insertion of the PD catheter. He had been treated with various antibiotics in the previous hospital. Over the course of treatment, he complained of diarrhea, which was diagnosed as acute enteritis. Upon admission to our hospital, he had no abnormal clinical signs except for a cloudy PD effluent. Blood examination showed a high C-reactive protein level (8.41 mg/dL), a white blood cell count in the PD fluid of 367 cell/µL (neutrophils 55.1%), and the presence of Candida parapsilosis. We initiated antifungal therapy and, during catheter removal, found evidence of intestine perforations by the PD catheter, which were successfully repaired. After catheter removal and intestine repair, he recovered and was discharged to continue undergoing hemodialysis. Based on our case, we recommend that intestine perforations should be considered as a cause of relapsing PD-related peritonitis with abdominal symptoms, particularly watery diarrhea. Furthermore, catheter removal and antifungal administration should be initiated earlier after the diagnosis of fungal peritonitis.

Invasive Candida Infections in Liver Transplant Recipients: Clinical Features and Risk Factors for Mortality

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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.