Systematic Review
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jul 27, 2019; 11(7): 596-606
Published online Jul 27, 2019. doi: 10.4254/wjh.v11.i7.596
Spontaneous fungal peritonitis: Micro-organisms, management and mortality in liver cirrhosis-A systematic review
Tooba Tariq, Furqan B Irfan, Mehdi Farishta, Brian Dykstra, Eric Martin Sieloff, Archita P Desai
Tooba Tariq, Mehdi Farishta, Eric Martin Sieloff, 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
Brian Dykstra, Department of Pulmonary and Critical Care 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
Author contributions: Tariq T, Irfan FB, Farishta M, Dykstra B and Desai AP contributed equally to the work; Tariq T and Irfan FB conceptualized and designed the study together; Irfan FB and Farishta M screened the studies for inclusion and carried out the data collection and data extraction; Dykstra B, Sieloff M and Desai AP carried out the analysis and critically analyzed the study; Tariq T, Irfan FB and Desai AP drafted the initial manuscript; all authors reviewed and approved the final manuscript as submitted.
Conflict-of-interest statement: None declared in agreement with all co-authors.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Tooba Tariq, MD, Instructor, Department of Internal Medicine, Western Michigan University, 1000 Oakland Drive, Kalamazoo, MI 49008, United States. toobatariq31@gmail.com
Telephone: +1-217-9045659 Fax: +1-269-3376222
Received: May 28, 2019
Peer-review started: May 29, 2019
First decision: June 10, 2019
Revised: June 15, 2019
Accepted: July 4, 2019
Article in press: July 5, 2019
Published online: July 27, 2019
Processing time: 60 Days and 6.3 Hours
ARTICLE HIGHLIGHTS
Research background

Spontaneous fungal peritonitis (SFP) is a devastating and underestimated complication of end stage liver disease (ESLD) which is defined as fungal infection of the ascitic fluid and the presence of ascitic neutrophil count of > 250 cells/mL. The combination of cirrhosis and critical illness causes acquired immunodeficiency leading to increased risk of developing SFP. There is limited literature regarding clinical course, risk factors, management and outcomes of SFP particularly in critically ill patients. With this study, we have compiled a systematic review of available data on SFP.

Research motivation

When compared to spontaneous bacterial peritonitis, SFP is less well recognized and is associated with higher mortality rates. In many cases, the clinical importance of isolating Candida from abdominal cultures is unknown and therapeutic approaches are largely undefined. Furthermore, the epidemiology and outcomes of patients with SFP have only been reported sporadically in literature. Hence, by performing a systematic review we aimed to increase the available knowledge regarding SFP.

Research objectives

The main objective of the study was to determine the prevalence of fungal micro-organisms and describe the risk factors, management and mortality rates of SFP in critically ill patients with cirrhosis.

Research methods

This is a systematic review of available studies identified using PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus databases. Inclusion criteria were 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 anti-fungal medications utilized for the management of SFP. The National Heart, Lung and Blood Institute quality assessment tools were used to assess internal validity and risk of bias for each included study.

Research results

Six observational studies were included in this systematic review. A total of 82 patients with SFP were identified in these studies. Candida albicans was the predominant fungal pathogen in majority of the cases (48-81.8%) followed by Candida krusei (15%-25%) and Candida glabrata (6.66%-20%). Antifungal therapy in SFP patients was utilized in 33.3% to 81.8% cases. The in-hospital mortality ranged from 33.3% to 100%, whereas 1-mo mortality ranged between 50% and 73.3%.

Research conclusions

SFP is not an uncommon complication associated with a worse prognosis in cirrhotic patients, particularly those with higher MELD and Child Pugh scores who fail to improve despite appropriate antibiotic treatment. Our study also showed that antifungal therapy is currently underutilized. Rapid initiation of antifungal therapy in the presence of septic shock and failure to respond to broad spectrum antibiotic regimen is crucial in the management of SFP.

Research perspectives

Future large-scale, prospective studies aimed at identifying the ideal timing and choice of anti-fungal therapy in patients at high-risk for developing SFP are needed. Also, research efforts should aim at determining appropriate non-cultural tests for SFP in order to improve the rapidity of diagnosis.