在混浊的流出物中寻求清晰：区分腹膜透析患者的真菌性和细菌性腹膜炎。
Seeking clarity within cloudy effluents: differentiating fungal from bacterial peritonitis in peritoneal dialysis patients.
机构信息
Department of Microbiology and Infectious Diseases, Sydney South West Pathology Service, Liverpool Hospital, Liverpool, Australia.
出版信息
PLoS One. 2011;6(12):e28247. doi: 10.1371/journal.pone.0028247. Epub 2011 Dec 1.
BACKGROUND
Fungal peritonitis is a serious complication of peritoneal dialysis (PD) therapy with the majority of patients ceasing PD permanently. The aims of this study were to identify risk factors and clinical associations that may discriminate between fungal from bacterial peritonitis.
METHODS
We retrospectively identified episodes of fungal peritonitis from 2001-2010 in PD patients at Liverpool and Westmead Hospitals (Australia). Fungal peritonitis cases were matched in a 1:2 ratio with patients with bacterial peritonitis from each institution's dialysis registry, occurring closest in time to the fungal episode. Patient demographic, clinical and outcome data were obtained from the medical records.
RESULTS
Thirty-nine episodes of fungal peritonitis (rate of 0.02 episodes per patient-year of dialysis) were matched with 78 episodes of bacterial peritonitis. Candida species were the commonest pathogens (35/39; 90% episodes) with Candida albicans (37%), Candida parapsilosis (32%) and Candida glabrata (13%) the most frequently isolated species. Compared to bacterial peritonitis, fungal peritonitis patients had received PD for significantly longer (1133 vs. 775 catheter-days; p = 0.016), were more likely to have had previous episodes of bacterial peritonitis (51% vs. 10%; p = 0.01), and to have received prior antibacterial therapy (51% vs. 10%; p = 0.01). Patients with fungal peritonitis were less likely to have fever and abdominal pain on presentation, but had higher rates of PD catheter removal (79% vs. 22%; p<0.005), and permanent transfer to haemodialysis (87% vs. 24%; p<0.005). Hospital length of stay was significantly longer in patients with fungal peritonitis (26.1 days vs. 12.6 days; p = 0.017), but the all-cause 30-day mortality rate was similar in both groups. Fluconazole was a suitable empiric antifungal agent; with no Candida resistance detected.
CONCLUSION
Prompt recognition of clinical risk factors, initiation of antifungal therapy and removal of PD catheters are key considerations in optimising outcomes.
背景
真菌性腹膜炎是腹膜透析（PD）治疗的严重并发症，大多数患者永久性停止 PD。本研究旨在确定可能区分真菌性和细菌性腹膜炎的危险因素和临床关联。
方法
我们回顾性地确定了 2001-2010 年在利物浦和韦斯特米德医院（澳大利亚）的 PD 患者中真菌性腹膜炎的发作。在每个机构的透析登记处，将真菌性腹膜炎病例与时间最接近的细菌性腹膜炎病例按 1:2 的比例进行匹配。从病历中获得患者的人口统计学、临床和结局数据。
结果
39 例真菌性腹膜炎（每例患者透析年发生率为 0.02 例）与 78 例细菌性腹膜炎相匹配。念珠菌是最常见的病原体（35/39；90%的病例），最常分离到的菌种是白色念珠菌（37%）、近平滑念珠菌（32%）和光滑念珠菌（13%）。与细菌性腹膜炎相比，真菌性腹膜炎患者的 PD 治疗时间明显更长（1133 与 775 个导管日；p=0.016），更有可能发生先前的细菌性腹膜炎（51%与 10%；p=0.01），并且更有可能接受过抗菌治疗（51%与 10%；p=0.01）。真菌性腹膜炎患者在就诊时不太可能出现发热和腹痛，但 PD 导管移除率更高（79%与 22%；p<0.005），永久性转至血液透析的比例更高（87%与 24%；p<0.005）。真菌性腹膜炎患者的住院时间明显更长（26.1 天与 12.6 天；p=0.017），但两组的 30 天全因死亡率相似。氟康唑是一种合适的经验性抗真菌药物；未检测到念珠菌耐药性。
结论
及时识别临床危险因素、启动抗真菌治疗和移除 PD 导管是优化结局的关键考虑因素。
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