What is the management for a peritoneal dialysis (PD) patient with Candida parapsilosis growth in the dialysate fluid?

Management of Candida parapsilosis in Peritoneal Dialysis Dialysate Fluid

For peritoneal dialysis patients with Candida parapsilosis growth in the dialysate fluid, immediate catheter removal combined with systemic antifungal therapy is strongly recommended as the definitive management approach. 1

Initial Management

• Catheter removal: Immediate removal of the peritoneal dialysis catheter is essential and should be performed within 24 hours of diagnosis 2, 3
• Antifungal therapy: Systemic antifungal treatment should be initiated immediately upon diagnosis 1
• Duration of therapy: Antifungal treatment should be continued for 10-14 days after catheter removal 4

Antifungal Selection

First-line options:

• Fluconazole: 400 mg daily (loading dose of 800 mg on day 1) for 14 days after the first negative culture 1
  • Particularly effective for C. parapsilosis infections as this species generally maintains susceptibility to azoles 5

Alternative options (for azole-resistant strains or treatment failures):

• Echinocandins (caspofungin, micafungin, anidulafungin) 1
  • Note: C. parapsilosis has higher MIC values for echinocandins compared to other Candida species, though they remain clinically effective 1
• Lipid formulation of amphotericin B: 3-5 mg/kg daily 1

Special Considerations

• Higher complication rate: C. parapsilosis peritonitis has a significantly higher complication rate (78%) compared to other Candida species (20%) 2
• Common complications: Abscess formation, persistent peritonitis after catheter removal, peritoneal adhesions, and mortality 2, 3
• Fluconazole monotherapy caution: Patients receiving fluconazole monotherapy for C. parapsilosis peritonitis have shown higher rates of severe complications compared to other Candida species 2

Monitoring and Follow-up

• Monitor for resolution of clinical symptoms (fever, abdominal pain) 3
• Follow dialysate cultures to confirm clearance of infection 1
• Assess for complications such as intra-abdominal abscess formation, which may require surgical intervention 2, 3

Prognosis and Outcomes

• CAPD resumption: Only about 29-62.5% of patients with C. parapsilosis peritonitis can successfully resume peritoneal dialysis 6, 3
• Mortality: Ranges from 14-18% in patients with C. parapsilosis peritonitis 6, 3
• Risk factors for poor outcomes: Prior gram-negative peritonitis, delayed catheter removal, and fluconazole monotherapy 6, 2

Pitfalls to Avoid

• Delaying catheter removal: Attempting to salvage the catheter is associated with higher mortality rates and treatment failure 7
• Inadequate duration of therapy: Premature discontinuation of antifungal therapy before complete resolution 4
• Premature catheter reinsertion: Wait at least 4-6 weeks after completion of antifungal therapy before attempting catheter reinsertion 4

Prevention

• Consider prophylactic antifungal therapy (nystatin) in programs with high baseline rates of fungal peritonitis 4
• Careful attention to aseptic technique during catheter care and exchanges 4