Risk of spontaneous fungal peritonitis in hospitalized cirrhotic patients with ascites: a systematic review of observational studies and meta-analysis

Introduction Spontaneous fungal peritonitis (SFP) is an infection of ascitic fluid occurring in cirrhotic patients. SFP prevalence varies from 0% to 41% of patients with spontaneous peritonitis (SP) and a positive ascitic fluid culture. Cirrhotic patients with SFP who fail to show improvement with empirical antibiotic therapy, before the identification of the fungal pathogen, have high mortality (89.5-100%). Although the weight of the disease is so dramatic, more recent guidelines on infections in cirrhosis do not consider SFP management. The aim of this meta-analysis was to investigate the association between hospitalization (at least 48-72 hours after admission) and risk of SFP. Evidence acquisition A literature search was performed on PubMed, Scopus and Web of Science to identify relevant studies published up to March 2, 2017. Only observational studies that specify the etiology of SP were included. Data were pooled using risk difference as a summary measure and corresponding 95% confidence interval (CI). Evidence synthesis Thirteen cohort studies were included in the meta-analysis (12 retrospective and one prospective). A pooled risk difference, using a random effects model, of nosocomial versus non-nosocomial SFP was 2.9% (95% CI, 0.4% to 5.3%, P=0.024) with a no significant heterogeneity among studies (P=0.090, I²=37%). Conclusions This meta-analysis suggests that hospitalization is related to a significant increase of SFP risk.