Spontaneous fungal peritonitis: Micro-organisms, management and mortality in liver cirrhosis-A systematic review

Table 1 Management, prognosis and mortality in cirrhotic patients with spontaneous fungal peritonitis

Study	Country, setting	Study design	Study population	Management	Mortality
				n (%)	n (%)
Hwang et al[10], 2014	South Korea, University Hospital	Retrospective, Cross-sectional	n = 416 patients	3rd generation cephalosporin (n = 15)	In-hospital: -
			SBP (n = 401)	Antifungal: n = 5 (33.3%)	1-mo: 11/15 (73.3%)
			SFP (n = 4)	Amphotericin B: n = 2	6-mo: 3/15 (20%)
			Polymicrobial SFP (n = 11)	Liposomal Amphotericin B: n = 1
				Fluconazole: n = 2
Hassan et al[9], 2014	Egypt, University Hospital	Prospective cohort study	n = 46 patients	Not described	In-hospital: 1/3 (33.33%)
			Control patients with no infection (n = 18)
			SFP (n = 4; only 3 patients described with ascitic fluid polymorphs > 250 cells/mm3)
Karvellas et al[11], 2015	(CATSS Database) from 28 medical centers in United States, Canada, Saudi Arabia	Retrospective cohort study	n = 126 patients	Anti-fungal: n = 9 (81.8%)	In-hospital: 11/11 (100%)
			SBP (n = 126)
			SFP and SBP (n = 11)
Bremmer et al[1], 20151	University of Pittsburgh, United States	Retrospective, cross-sectional study	n = 25	Antifungal: n = 15 (60%)	In hospital: 15/25 (60%)
			SFP (n = 25)		One mo: 14/25 (56%)
Lahmer, et al[2], 2016	University Hospital, Germany	Retrospective, cross-sectional study	n = 208 SFP (n = 20)	Antibiotic pretreatment: SFP n = 17 Antifungal: n = 6 (30% of SFP)	In-hospital: 18/20 (90%)
			SBP (n = 28)
Gravito-Soares et al[6], 2017	University of Coimbra, Coimbra, Portugal	Retrospective, case–control study	n = 231	Cefotaxime n = 231	1 -mo: 4/8
			SFP (n = 3)	Antifungal: n = 5/8 (62.5%)	(50%)
			Polymicrobial SFP (n = 5)	Fluconazole: n = 3
			SBP (n = 119)	Caspofungin: n = 1
				Amphotericin B: n = 1

¹The study was described as a retrospective cohort study design but in the absence of a comparative non-exposure/control group we decided it more appropriately fitted the description of a cross—sectional study. SBP: Spontaneous bacterial peritonitis; SFP: Spontaneous fungal peritonitis.

Table 2 Quality assessment of included observational cohort and cross-sectional studies according to NHBLI Quality Assessment Tool

	Hwang et al[10], 2014	Hassan et al[9], 2014	Karvellas et al[11], 2015	Bremmer et al[1], 2015	Lahmer et al[2], 2016
1 Was the research question or objective in this paper clearly stated?	Yes	Yes	Yes	Yes	Yes
2 Was the study population clearly specified and defined?	Yes	Yes	Yes	Yes	Yes
3 Was the participation rate of eligible persons at least 50%?	Yes	Yes	Yes	Yes	Yes
4 Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?	Yes	Yes	Yes	Yes	Yes
5 Was a sample size justification, power description, or variance and effect estimates provided?	No	No	No	No	No
6 For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?	Yes	Yes	Yes	Yes	Yes
7 Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?	Yes	Yes	Yes	Yes	Yes
8 For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?	NA	NA	Yes	NA	NA
9 Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?	Yes	Yes	Yes	Yes	Yes
10 Was the exposure(s) assessed more than once over time?	No	No	No	No	No
11 Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?	Yes	Yes	Yes	Yes	Yes
12 Were the outcome assessors blinded to the exposure status of participants?	No	No	No	No	No
13 Was loss to follow-up after baseline 20% or less?	Yes	Yes	Yes	Yes	Yes
14 Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?	No	Yes	Yes	Yes	Yes
Rating	Good	Good	Good	Good	Good

Table 3 Quality assessment of included case-control studies according to NHBLI Quality Assessment Tool

Gravito-Soares et al[6], 2017
1 Was the research question or objective in this paper clearly stated?	Yes
2 Was the study population clearly specified and defined?	Yes
3 Did the authors include a sample size justification?	No
4 Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?	Yes
5 Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?	No
6 Were the cases clearly defined and differentiated from controls?	Yes
7 If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible?	NA
8 Was there use of concurrent controls?	No
9 Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?	Yes
10 Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?	Yes
11 Were the assessors of exposure/risk blinded to the case or control status of participants?	No
12 Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?	Yes
Rating	Fair