What is the management of Acremonium (a type of fungus) peritonitis in an immunocompromised patient with a history of kidney disease or dialysis (peritoneal dialysis)?

Management of Acremonium Peritonitis in Peritoneal Dialysis

Remove the peritoneal dialysis catheter immediately and initiate systemic antifungal therapy with voriconazole as first-line treatment, or alternatively amphotericin B or posaconazole. 1

Immediate Management Steps

Catheter Removal

• Catheter removal is almost always necessary for successful treatment of fungal peritonitis, including Acremonium species. 2, 3
• Remove the catheter promptly upon diagnosis, as systemic antifungal therapy alone yields inconsistent results in fungal peritonitis without source control. 3
• Wait at least 2 weeks after catheter removal before placing a new catheter to allow adequate treatment and resolution of infection. 2, 4

Antifungal Therapy Selection

First-line systemic treatment:

• Voriconazole is the recommended first-line agent for Acremonium infections based on clinical outcomes. 1
• Alternative agents include amphotericin B or posaconazole if voriconazole is contraindicated or unavailable. 1

Key pharmacologic considerations:

• Acremonium species demonstrate variable in vitro susceptibility, with recent studies showing high MICs for most agents except terbinafine. 1
• Despite in vitro resistance patterns, clinical success has been reported with voriconazole, amphotericin B, and posaconazole. 1
• Avoid intraperitoneal amphotericin B due to risk of chemical peritonitis. 2, 4

Treatment Duration

• Continue systemic antifungal therapy for 2-3 weeks, guided by clinical response. 2, 4
• Monitor for resolution of symptoms including clearing of dialysate, resolution of abdominal pain, and normalization of inflammatory markers. 2

Clinical Context and Pitfalls

Risk Factors to Address

• Prior antibiotic use is present in 87.3% of fungal peritonitis cases and represents a major risk factor. 5
• High peritonitis rates (one episode every 5.1 months versus 9.9 months in unaffected patients) predispose to fungal superinfection. 5

Common Pitfalls

• Do not delay catheter removal: Early removal (within 1 week) is associated with better outcomes in fungal peritonitis. 5
• Do not use aminoglycosides if residual renal function exists: These agents cause nephrotoxicity and compromise residual function, which is crucial for outcomes. 2
• Acremonium grows slowly in culture; incubate plates for at least 2 weeks to avoid false-negative results. 1

Surgical Considerations Beyond Catheter Removal

• Surgery for infected tissue removal may be necessary if there is evidence of osteomyelitis, septic arthritis, or progressive infection despite medical therapy. 1
• Consider surgical debridement if infection extends beyond the peritoneum. 1

Prognosis and Follow-up

• Fungal peritonitis carries mortality rates exceeding 50% in some series, though Acremonium-specific mortality data are limited. 1
• Of patients who have catheters replaced 2-8 weeks after diagnosis, approximately 91% can successfully return to peritoneal dialysis. 5
• Technique failure occurs in 30.8% of fungal peritonitis cases with aggressive management including early antifungal therapy and deferred catheter replacement. 6
• Monitor closely for hepatic dysfunction during antifungal therapy, particularly with amphotericin B-based regimens. 6

Alternative Considerations

While combination therapy with voriconazole plus terbinafine has shown success in some Acremonium infections at other sites, evidence specific to peritoneal dialysis-associated peritonitis is limited to case reports. 1 The standard approach remains monotherapy with an azole or polyene plus catheter removal. 1, 3