Oral nystatin for the prevention of antibiotic-related fungal peritonitis in peritoneal dialysis patients: a systematic review and meta-analysis of randomized and observational studies

Objectives: Fungal peritonitis is a severe complication in peritoneal dialysis (PD) patients, frequently occurring after antibiotic exposure. This systematic review and meta-analysis assessed whether oral nystatin administered concomitantly with antibiotics reduces the incidence of antibiotic-related fungal peritonitis (ARFP) compared with no prophylaxis. Methods: Following PRISMA guidelines, MEDLINE, PubMed and Embase were searched up to 1 October 2025 for randomized and observational studies enrolling adult PD patients who received systemic antibiotics with or without oral nystatin prophylaxis. The primary outcome was the odds of ARFP. ORs were pooled using random-effects models. This systematic review and meta-analysis was registered in PROSPERO (CRD420251154535). Results: Four prospective observational studies and one randomized controlled trial (RCT), comprising 2060 PD patients, were included. ARFP yielded 13 events among 1044 peritonitis episodes in the nystatin-treated patients versus 31 among 1016 in the control group (OR 0.53; 95% CI, 0.18-1.57). In the two studies (one observational and one RCT) reporting prescription-level data, nystatin was significantly associated with ARFP reduction (7 events out of 2205 prescriptions in the prophylaxis group versus 16/1724; OR 0.35; 95% CI, 0.15-0.87). Conclusions: Oral nystatin administered during antibiotic therapy was associated with a numerically lower rate of ARFP in PD patients, although all pooled estimates were based on unadjusted data and a limited number of events, thus precluding any certain causal inference. However, given its favourable safety profile and local action, nystatin may represent a valid candidate for a prophylactic strategy warranting further evaluation in contemporary, adequately powered randomized trials.