Introduction
Bacterial infections are more prevalent than fungal infections among individuals undergoing peritoneal dialysis. Nevertheless, fungal-induced peritonitis has a greater incidence of illness and death compared to bacterial infections. Documented consequences include sclerosing peritonitis (a unique type of inflammation in the peritoneum that affects both the inner and outer surfaces of the abdominal cavity.), scar tissue formations leading to intestinal blockages or restriction, infiltration of the intestine wall and the development of abscesses. The occurrence of infection spreading outside the peritoneum is uncommon, and the fatality rate is typically associated with pre-existing medical conditions.
What Are the Signs and Symptoms?
The symptoms and signs of fungal peritonitis in patients undergoing peritoneal dialysis are identical to those observed in cases of bacterial peritonitis. The most common are the following:-
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Turbid (cloudy) dialysate (the fluid used in dialysis to remove waste products and excess fluids from the blood).
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Stomach discomfort.
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Abdominal pain (typically spread out pain).
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Nausea.
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Vomiting.
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Diarrhea.
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Low-grade temperature.
Most patients exhibit a heightened body temperature. Abdominal examination commonly reveals indications of appendix rupture, such as widespread sensitivity with protective muscle contractions, sensitivity upon release, abdominal swelling, and reduced intestinal noises. The dialysate's inadequate return during bouts of fungal peritonitis is more common when molds cause the infection, as they have the potential to obstruct catheter ports.
What Are the Various Causative Factors?
Possible factors leading to fungal contamination of peritoneal fluid include
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Hygienic failures occur when abdominal catheters are placed in pouches containing dialysate, a fluid that eliminates impurities during dialysis.
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Infections at the site where the catheter enters the skin.
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Intestinal perforation.
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Abdominal wounds.
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The migration of fungi across the bowel wall into the peritoneum.
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A recent history of bacterial peritonitis and exposure to antibacterial medications heightens the risk of fungal peritonitis. The correlation between recent antibiotic usage and occurrences of fungal peritonitis.
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Antibiotics can increase the likelihood of fungal peritonitis by altering the patient's natural skin and bowel bacteria composition, leading to an overgrowth of yeast species.
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There is a growing trend of fungal infections in patients who undergo emergency peritoneal dialysis in the hospital. This could be because these patients are very sick, they are also receiving antibacterial treatment, or the dialysis is being performed by staff unfamiliar with peritoneal dialysis techniques.
Patients with human immunodeficiency virus (HIV) infection who undergo long-term peritoneal dialysis are more prone to developing peritonitis caused by yeasts compared to other patients undergoing long-term peritoneal dialysis.
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Fungal infection outside the peritoneal cavity.
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Surgery was performed on the abdomen.
Other peritonitis outbreaks occur due to the following:
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The Candida peritonitis outbreaks are caused by contamination of water baths used to heat dialysate solutions and exposure to environmental pigeon droppings.
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Contact with dirt while gardening or recreational activities can result in peritonitis caused by specific types of molds.
What Is the Treatment Method?
The treatment objectives are to eliminate the infection and maintain the integrity of the peritoneum for potential utilization in peritoneal dialysis. The methodology employed is as follows:
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The peritoneum should be thoroughly rinsed until the fluid that comes back is transparent; this helps to avoid the formation of adhesions and reduces the amount of fungi present.
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Administration of systemic antifungal medications is recommended when a calcofluor white or Gram stain indicates the presence of yeast or hyphae. The culture results determine the choice of subsequent therapy, susceptibility of the organism, and patient response.
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The catheter should be promptly withdrawn upon detecting fungus through a microscope or culture, and the patient should be transitioned to hemodialysis.
What Are the Different Medications Recommended During Treatment?
The following discussion pertains to selecting a particular antifungal agent and the appropriate duration of treatment. The selection of an antifungal agent depends on the particular infecting organism and its duration:
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Initial Treatment: To provide initial treatment for fungal peritonitis until the results of cultures are available, Fluconazole is administered at 200 mg on the first day, followed by a daily dose of 100 to 200 mg. Given Fluconazole's high bioavailability, oral treatment is suitable for most patients. Patients who are unable to take oral drugs, have poor gastrointestinal absorption or are critically unwell should get intravenous (IV) therapy at the exact dosage. For patients who have previously been treated with azole antifungals, intravenous administration is advised; once cultures are obtained, subsequent therapy can be customized to target the specific organism that has been identified.
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Presence of Candida Species: If Candida species are detected, it is advisable to conduct susceptibility investigations to guide the appropriate treatment. In general, Candida species are susceptible to Fluconazole. It can be administered orally at 200 mg on the first day, followed by a daily dose of 100 to 200 mg. The typical period of therapy ranges from two to four weeks.
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Presence of Fungus: If the fluid cultures show the presence of a fungus, intravenous Amphotericin B deoxycholate will be administered until the specific organism is identified and the most suitable antifungal medication can be administered. Oral Voriconazole is the recommended treatment for Aspergillus species or Scedosporium apiospermum complex. Patients should undergo a minimum four-week treatment regimen until all symptoms and indicators are resolved.
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Infection by Dematiaceous Molds: Infections caused by dematiaceous molds should be managed with oral Voriconazole. However, in certain situations, intravenous Amphotericin B has also shown effectiveness. Patients should undergo a minimum four-week treatment regimen until all symptoms and indicators are completely resolved.
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Renal Function Dysfunction: The use of lipid formulations of Amphotericin B is not widely documented, but they are expected to be equally efficacious as the deoxycholate formulation. Patients with remaining renal function should utilize lipid formulations to minimize the risk of kidney damage. These medicines can also be administered to patients who suffer from severe infusion-related responses to the deoxycholate formulation. The recommended dosage is 3 to 5 milligrams per kilogram every day.
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Additional Treatment For Peritoneal Dialysis: Amphotericin B has sometimes been administered directly into the peritoneal cavity as the only additional treatment in exceptional cases where the peritoneal dialysis catheter has not been removed. Nevertheless, employing this treatment protocol due to its inconsistent efficacy in eradicating infections, its tendency to induce abdominal pain during administration, and its potential to promote the development of adhesions, resulting in the loss of the peritoneum as a dialyzing membrane. Furthermore, removing the catheter during the initial treatment of fungal peritonitis prevents the potential for administering antifungal drugs directly into the peritoneal cavity.
Conclusion
Fungal peritonitis is an uncommon condition that is linked to greater rates of illness and death compared to bacterial peritonitis. It is essential to promptly identify and remove the catheter in cases of fungal peritonitis. The identification of the condition relies heavily on cultural findings, as the signs and symptoms typically do not vary from those of bacterial peritonitis. Fungal peritonitis is more likely to occur in individuals with low levels of blood albumin and those who require mandatory peritoneal dialysis treatment.
