What is the recommended management approach for a patient with Acremonium (a type of fungus) peritonitis, likely undergoing peritoneal dialysis (PD) and potentially immunocompromised?

Management of Acremonium Peritonitis in Peritoneal Dialysis

Remove the peritoneal dialysis catheter immediately and initiate systemic antifungal therapy with voriconazole as first-line treatment. 1

Immediate Actions

Catheter removal is mandatory and should be performed promptly upon diagnosis - this is almost always necessary for successful treatment of fungal peritonitis, including Acremonium species. 1 Unlike bacterial peritonitis where catheter salvage may be attempted, fungal peritonitis requires definitive catheter removal because systemic antifungal therapy alone yields inconsistent results. 2

• Remove the catheter as soon as the diagnosis is established, ideally within the first few days of presentation. 1, 2
• Do not delay catheter removal hoping for medical management alone - this approach has historically failed in Acremonium peritonitis cases. 3, 2

Antifungal Therapy Selection

Start voriconazole immediately as first-line systemic antifungal therapy upon diagnosis or strong clinical suspicion of Acremonium peritonitis. 1 This recommendation comes from the International Society of Peritoneal Dialysis and Infectious Diseases Society of America guidelines.

Alternative agents if voriconazole is contraindicated or unavailable:

• Amphotericin B (lipid formulation preferred at 3-5 mg/kg daily) 1
• Posaconazole as a second alternative 1

Important considerations about Acremonium susceptibility:

• Acremonium species demonstrate variable and often poor in vitro susceptibility to most antifungal agents, with high MICs documented for many standard therapies. 1
• This underscores why catheter removal is non-negotiable - medical therapy alone is insufficient. 1, 2

Treatment Duration and Timing

Continue systemic antifungal therapy for 2-3 weeks, guided by clinical response. 1 The treatment timeline should follow this sequence:

1. Initiate antifungals immediately (ideally within 3-4 days of presentation) 4
2. Remove catheter promptly upon diagnosis 1, 2
3. Wait at least 2 weeks after catheter removal before considering placement of a new catheter to allow adequate treatment and resolution of infection 1
4. Total antifungal duration: 2-3 weeks from catheter removal, adjusted based on clinical response 1

Monitoring for treatment response:

• Clearing of dialysate effluent 1
• Resolution of abdominal pain 1
• Normalization of inflammatory markers 1

Critical Pitfalls to Avoid

Do not rely on early negative cultures - Acremonium grows slowly in culture, and plates must be incubated for at least 2 weeks to avoid false-negative results. 1 If clinical suspicion is high based on cloudy effluent and symptoms, proceed with catheter removal even if initial cultures are negative.

Avoid aminoglycosides if any residual renal function exists - these agents cause nephrotoxicity and will compromise residual kidney function, which is crucial for patient outcomes and potential return to peritoneal dialysis. 1

Do not attempt catheter salvage strategies - while one case report described experimental use of in-situ lyticase enzyme during the COVID-19 pandemic when catheter removal was delayed 5, this is not standard practice and should only be considered in extraordinary circumstances where catheter removal is impossible.

Special Considerations for High-Risk Patients

For immunocompromised or critically ill patients, the same aggressive approach applies but with heightened urgency:

• These patients have higher mortality risk with fungal peritonitis (exceeding 50% in some series) 1
• Antifungal therapy is particularly critical in this population 6
• Consider more intensive monitoring and potentially longer antifungal courses 1

Surgical Considerations Beyond Catheter Removal

Evaluate for extension of infection beyond the peritoneum - if there is evidence of osteomyelitis, septic arthritis, or progressive infection despite medical therapy, surgical debridement of infected tissue may be necessary. 1

Return to Peritoneal Dialysis

After successful treatment:

• Minimum 2-week waiting period after catheter removal before placing new catheter 1
• Ensure complete resolution of symptoms and normalization of inflammatory markers before catheter replacement 1
• Some patients may require permanent transition to hemodialysis if peritoneal membrane function is compromised 4