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
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.

Keywords: Spontaneous fungal peritonitis, Bacterial peritonitis, Liver, Cirrhosis, Critical

Core tip: Spontaneous fungal peritonitis (SFP) in patients with cirrhosis is associated with high in-hospital mortality rate of 33.3% to 100% and 1-mo mortality rate of 50% to 73.3%. In our systematic review of the literature, despite such high mortality rates, the condition is under diagnosed and antifungal therapy is underutilized; 33.3% to 81.8% SFP patients received anti-fungal therapy. High clinical suspicion, new methods of early diagnosis and empiric treatment in critically ill patients with peritonitis may improve outcomes.