What is the recommended treatment for Candida in ascites (accumulation of fluid in the peritoneal cavity)?

Treatment of Candida in Ascites

For Candida in ascites, an echinocandin (caspofungin, micafungin, or anidulafungin) is the recommended first-line treatment, with fluconazole as an alternative for susceptible species. 1

First-Line Treatment Options

Echinocandins (Preferred)

• Caspofungin: 70 mg loading dose, then 50 mg daily IV 1, 2
• Micafungin: 100 mg daily IV 2, 3
• Anidulafungin: 200 mg loading dose, then 100 mg daily IV 1, 2

Echinocandins are preferred for initial therapy due to:

• Broad spectrum activity against most Candida species
• Favorable safety profile
• Effectiveness against fluconazole-resistant strains
• Recommendation by IDSA guidelines for invasive candidiasis 1

However, it's important to note that echinocandins may achieve lower concentrations in ascites fluid compared to plasma, which could affect their fungicidal activity 4. Despite this limitation, they remain the recommended first-line agents.

Alternative Treatment

• Fluconazole: 400-800 mg (6-12 mg/kg) daily for fluconazole-susceptible Candida species 1
  • Consider for step-down therapy after initial echinocandin treatment if the isolate is susceptible
  • Achieves good penetration into most body fluids

Species-Specific Considerations

For Candida glabrata

• First choice: Echinocandin (due to frequent fluconazole resistance) 1, 2
• Alternative: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without oral flucytosine 25 mg/kg 4 times daily 1

For Candida krusei

• First choice: Echinocandin 1, 2
• Alternative: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1

Duration of Treatment

• Continue antifungal therapy for at least 14 days after the last positive culture 1
• For persistent candidemia or complicated intra-abdominal infections, longer treatment may be necessary

Additional Management Considerations

1. Source control: Surgical intervention or drainage of infected ascites is strongly recommended when feasible 1
2. Catheter management: If a peritoneal dialysis catheter is present, removal is strongly recommended 5
3. Risk assessment: Consider severity of illness and risk factors for fluconazole resistance when selecting therapy 1

Special Populations

Critically Ill Patients

• Echinocandins are strongly preferred as initial therapy 1
• Consider combination therapy in severe cases

Cirrhotic Patients

• Echinocandins are preferred due to minimal hepatic metabolism 2
• Monitor liver function tests during treatment

Common Pitfalls to Avoid

1. Delayed treatment: Fungal peritonitis has high mortality; initiate appropriate antifungal therapy promptly upon identification of Candida
2. Inadequate source control: Failure to drain infected ascites can lead to treatment failure
3. Inappropriate step-down therapy: Ensure susceptibility testing before de-escalating from an echinocandin to fluconazole
4. Insufficient duration: Premature discontinuation of antifungal therapy may lead to relapse

While some studies suggest that antifungal therapy may not improve outcomes in all cases of community-acquired peritonitis with Candida isolation 6, the IDSA guidelines still recommend antifungal treatment for Candida isolated from normally sterile sites, including ascites 1.