Does antifungal prophylaxis with daily oral fluconazole reduce the risk of fungal peritonitis in peritoneal dialysis patients? The Pan Thames Renal Audit

Empirical antifungal therapy for health care-associated intra-abdominal infection: a retrospective, multicentre and comparative study

BACKGROUND

Current guidelines recommend using antifungals for selected patients with health care-associated intra-abdominal infection (HC-IAI), but this recommendation is based on a weak evidence. This study aimed to assess the association between early empirical use of antifungals and outcomes in intensive care unit (ICU) adult patients requiring re-intervention after abdominal surgery.

METHODS

A retrospective, multicentre cohort study with overlap propensity score weighting was conducted in three ICUs located in three medical institutions in France. Patients treated with early empirical antifungals for HC-IAI after abdominal surgery were compared with controls who did not receive such antifungals. The primary endpoint was the death rate at 90 days, and the secondary endpoints were the death rate at 1 year and composite criteria evaluated at 30 days following the HC-IAI diagnosis, including the need for re-intervention, inappropriate antimicrobial therapy and death, whichever occurred first.

RESULTS

At 90 days, the death rate was significantly decreased in the patients treated with empirical antifungals compared with the control group (11.4% and 20.7%, respectively, p = 0.02). No differences were reported for the secondary outcomes.

CONCLUSION

The use of early empirical antifungal therapy was associated with a decreased death rate at 90 days, with no effect on the death rate at 1 year, the death rate at 30 days, the rate of re-intervention, the need for drainage, and empirical antibiotic and antifungal therapy failure at 30 days.

The efficacy of fluconazole for anti-fungal prophylaxis in peritoneal dialysis patients: A systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

The efficacy of fluconazole as a prophylactic strategy in patients with chronic kidney disease (CKD) on peritoneal dialysis (PD) with prior antibiotic exposure is controversial in the current literature. This study aimed to compare a strategy of fluconazole prophylaxis versus no-prophylaxis for patients in PD on antibiotics for previous episodes of peritonitis.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) comparing fluconazole prophylaxis with no prophylaxis for PD-related peritonitis. The search was conducted on PubMed, EMBASE, and Cochrane Central in January 23, 2023. The outcome of interest was the occurrence of fungal peritonitis (FP).

RESULTS

We included six studies (1 RCT, 5 observational) with 4515 occurrences of peritonitis, of which 1098 (24.8%) received fluconazole prophylaxis in variable doses, whereas 3417 (75.6%) did not receive prophylaxis during peritonitis episodes. Overall, fluconazole prophylaxis was associated with a lower incidence of FP (OR 0.22; 95% CI 0.12-0.41; p<0.001; I2=0%). Subgroup analysis of studies that administered daily doses of fluconazole also demonstrated a reduced incidence of FP in patients who received antifungal prophylaxis (OR 0.31; CI 0.14-0.69; p=0.004; I2=0%).

CONCLUSIONS

In this meta-analysis of 4515 episodes of PD-related peritonitis, prophylaxis with fluconazole significantly reduced episodes of FP as compared with no antifungal prophylaxis.

A case of Neurospora sitophila causing PD peritonitis

We describe a rare case of fungal peritoneal dialysis (PD) peritonitis caused by the ascomycete fungus Neurospora sitophila (N. sitophila). The patient had little response to initial antibiotics and PD catheter removal was necessary for source control. The fungal biomarker β-d-glucan (BDG) was positive prior to N. sitophila being cultured and remained positive for 6 months after discharge. Use of BDG early in the assessment of PD peritonitis may reduce time to definitive therapy in fungal peritonitis.

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.

Talaromyces (Penicillium) Species Infection in the Central Nervous System

Talaromycosis typically occurs as an opportunistic infection among immunocompromised individuals. Infection caused by species other than T. marneffei is uncommon. While most reported cases describe infection in the lungs, we report an extremely rare intracranial Talaromyces species infection. This 61-year-old with end-stage renal disease who was unwell for the previous two months, presented with fever and worsening confusion lasting for three days. Lumbar puncture was suggestive of meningitis. Cerebrospinal fluid (CSF) culture was later confirmed to be Penicillium chrysogenum. The patient was co-infected with Group B Streptococcus sepsis. He improved with amphotericin B and ceftriaxone and was discharged with oral itraconazole for four weeks. However, he died of unknown causes two weeks later at home. Talaromyces species infection in the central nervous system is uncommon. This case highlighted a rare but life-threatening fungal meningitis. Among the four reported cases worldwide, none of the patients survived.

Systemic Endotoxin in Peritoneal Dialysis Patients

Previous reports linked systemic endotoxemia in dialysis patients to increased markers of inflammation, cardiovascular disease, and mortality. Many peritoneal dialysis (PD) patients use acidic, hypertonic dialysates, which could potentially increase gut permeability, resulting in systemic endotoxemia. However, the results from studies measuring endotoxin in PD patients are discordant. We therefore measured systemic endotoxin in 55 PD outpatients attending for routine assessment of peritoneal membrane function; mean age 58.7 ± 16.4 years, 32 (58.2%) male, 21 (38.2%) diabetic, median duration of PD treatment 19.5 (13 - 31) months, 32 (58.2%) using 22.7 g/L dextrose dialysates, and 47 (85.5%) icodextrin. The median systemic endotoxin concentration was 0.0485 (0.0043 - 0.103) Eu/mL. We found no association between endotoxin levels and patient demographics, markers of inflammation, serum albumin, N-terminal pro-brain natriuretic peptide, extracellular volume measured by bioimpedance, blood pressure, PD prescriptions or peritoneal membrane transporter status, or medications. The measurement of endotoxin can be lowered by failure to effectively release protein-bound endotoxin prior to analysis and increased by contamination when taking blood samples and processing and storing the samples. Additionally, contamination with β-glucan from fungal cell walls and the use of different assays to analyze endotoxin can also give differing results. These factors may help to explain the disparate results reported in different studies. Our study would suggest that exposure to standard peritoneal dialysates does not substantially increase systemic endotoxin. However, until endotoxin assays can measure free and bound endotoxin separately, the role of endotoxin causing inflammation in PD patients remains to be determined.

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.

Portable and wearable dialysis devices for the treatment of patients with end-stage kidney failure: Wishful thinking or just over the horizon?

Dialysis is a life-sustaining treatment for patients with end-stage kidney disease. In a different context, for many patients this treatment is the focal point around which their life revolves, not only due to the time spent travelling to and from treatment sessions and the time dedicated to the dialysis treatment itself, but also due to the accompanying dietary and fluid restrictions and medication burden. Wearable and portable dialysis devices could potentially improve patient quality of life by allowing patients to continue with their daily activities of life while undergoing dialysis, as well as by loosening-or removing entirely-dietary and fluid restrictions and reducing pill burden. Advances in nanotechnology manufacturing coupled with advances in electronics and miniaturisation have allowed a new generation of wearable and portable dialysis devices to be developed which are now undergoing large animal and patient clinical trials. We are therefore potentially at a new dawn in the treatment of dialysis patients with the first generation of wearable and portable dialysis devices, which may well revolutionise the treatment and quality of life for patients with end-stage kidney disease.

Characteristics and outcomes of fungal peritonitis in a modern North American cohort

INTRODUCTION

Peritonitis remains a common complication of peritoneal dialysis (PD). Although representing only 1 - 12% of overall peritonitis in dialysis patients, fungal peritonitis (FP) is associated with serious complications, including technique failure and death. Only scarce data have been published regarding FP outcomes in modern cohorts in North America. In this study we evaluated the rates, characteristics and outcomes of FP in a major North American PD center.

METHODS

We conducted a retrospective cohort study including all fungal peritonitis episodes among peritoneal dialysis patients followed in a large PD center between January 2000 and February 2013. Our pre-specified endpoints included rates of FP, characteristics, outcomes and determinants of death.

RESULTS

Thirty-six episodes of FP were identified during the follow-up period (one episode per 671 patient-months), representing 4.5% of the total peritonitis events. Patients' mean age and peritoneal dialysis vintage were 61.3 ± 15.5 and 2.9 (1.5 - 4.8) years, respectively. Of the 36 episodes of FP, seven (19%) resulted in death and 17 (47%) led to technique failure with permanent transfer to hemodialysis. Surprisingly, PD was eventually resumed in 33% of cases with a median delay of 15 weeks (interquartile range 8 - 23) between FP and catheter reinsertion. In a univariable analysis, a higher Charlson comorbidity index (Odds ratio [OR] 3.25 per unit increase, 95% confidence interval [CI] 1.23 - 8.58) and PD fluid white blood cell (WBC) count greater than 3,000/mm(3) at presentation (OR 6.56, 95% CI 1.05 - 40.95) predicted death.

CONCLUSION

While fungal peritonitis is still associated with a high frequency of death and technique failure, one third of our patients eventually returned to PD. Patients with a high burden of comorbidities appear at higher risk of death. We postulate that the high mortality associated with FP is partially related to the severity of comorbidity among patients with FP, rather than the infection per se. Importantly, PD can be resumed in a significant proportion of cases.

Long-term peritoneal dialysis experience: quality control supports the use of fluconazole to prevent fungal peritonitis

BACKGROUND

Fungal peritonitis (FP) is rare, but it is associated with high morbidity and mortality.

PATIENTS AND METHODS

A prospective study was conducted based on the peritonitis episodes registry to evaluate FP rate, possible risk factors, and outcomes. The impact of prophylactic intervention with oral fluconazole was evaluated.

RESULTS

Over 24 years of experience, 417 patients underwent peritoneal dialysis (PD), followed for 956 patient-years. By the end of the study, the peritonitis rate reached 0.47 episodes per patient-year of treatment (ep/pt-y). FP was detected in 24 patients. The global rate of FP was 0.03 ep/pt-y (4.8%). Candida species accounted for 92% of the FP. Risk factors identified: recent use of antibiotics in 63% (13 episodes of bacterial peritonitis and 2 exit-site infections (ESI)) and immunosuppressive therapy in 8%. While rare, the FP proportion was still observed to increase from the beginning of the program, reaching 7.8% (0.05 ep/pt-y). A strategy of antifungal prophylaxis with oral fluconazole during peritonitis or ESI antibiotic therapy was adopted, which allowed thereafter a 4.0% falling FP proportion (by study end, rate of 0.01 ep/pt-y). Catheter removal occurred in all patients. The mortality rate was 12.5%. Reinsertion of dialysis catheter was attempted in 4 patients and PD was successfully resumed in 3 patients.

CONCLUSIONS

FP was associated with high mortality and required early removal of the catheter in all patients. Recent use of antibiotics was a predisposing factor to PF. The quality control process determined a prophylactic strategy and reduction of PF after introduction of oral fluconazole was implemented.