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.

Fungal peritonitis in peritoneal dialysis patients: successful prophylaxis with fluconazole, as demonstrated by prospective randomized control trial

OBJECTIVES

To determine whether oral administration of the antifungal fluconazole during the entire period of treatment of bacterial peritonitis (BP), exit-site infection (ESI), or tunnel infection (TI) prevents later appearance of fungal peritonitis (called secondary) in patients with chronic kidney disease stage 5 in a peritoneal dialysis (PD) program. ♢

PATIENTS AND METHODS

All patients treated in the PD program in RTS Ltda Sucursal Caldas, during the period 1 June 2004 to 30 October 2007 were screened. Patients that had infectious bacterial complications (BP, ESI, TI) were included in a prospective randomized trial to receive or not receive oral fluconazole (200 mg every 48 hours) throughout the time period required by the administration of therapeutic antibiotics via any route. It was evaluated whether the fungal peritonitis complication appeared within 30 - 150 days following the end of antibacterial treatment. Based on local results, the sample size necessary to obtain statistically significant results was determined to be 434 episodes of peritonitis. ♢

RESULTS

The 434 episodes of peritonitis presented between the previously specified dates and during this same period there were 174 ESI or TI, of which only 52 received oral antibiotic treatment. Information in relation to consumption of antibiotics for purposes other than BP, ESI, and TI was not reliable and thus this variable was excluded. Among the episodes of peritonitis, 402 (92.6%) were of bacterial origin and 32 (7.3%) were mycotic, mainly Candida species [30 (93.75%)]. Of the fungal peritonitis, 14 (43.73%) were primary (without prior use of antibiotics) and 18 (56.25%) were secondary. In the group of patients that received prophylaxis with fluconazole (210 for BP and 26 for ESI or TI), only 3 occurrences of fungal peritonitis were observed within 30 - 150 days of its administration, which is opposite to the group without prophylaxis (210 for BP and 26 for ESI or TI), in which 15 occurrences of fungal peritonitis were detected. Statistical analysis of the group of patients with BP found comparisons of the proportions of those receiving fluconazole (0.92%) or not (6.45%) presented a highly significant difference in favor of prophylaxis (p = 0.0051, Z = 2.8021). Given that only 1 patient in each group with ESI or TI, with or without prophylaxis, presented the complication fungal peritonitis, it was concluded that this result was not statistically significant. During laparoscopic surgery attempting reintroduction of the peritoneal catheter, it was found that 11 patients had severe adhesions or peritoneal fibrosis leading to obliteration of the peritoneal cavity. In 19 patients, reintroduction of the catheter was possible and the patients returned to PD without consequence. ♢

CONCLUSION

In patients with bacterial peritonitis, administration of prophylactic oral fluconazole throughout the time they received antibiotics significantly prevented the appearance of secondary fungal peritonitis.