Duration of Fungal Prophylaxis After Peritoneal Dialysis Catheter Removal
Continue antifungal therapy for 10-14 days after peritoneal dialysis catheter removal for fungal peritonitis, then discontinue prophylaxis. 1
Standard Treatment Duration
- Antifungal treatment should be administered for 10 days to 2 weeks following catheter removal in all cases of fungal peritonitis. 1
- The duration is counted from the day of catheter removal, not from the initial diagnosis of infection. 2
- This recommendation applies specifically to peritoneal dialysis-associated fungal infections, which differ from other catheter-related candidemia in their management approach. 1
Rationale for Time-Limited Therapy
- Unlike catheter-related bloodstream infections where antifungals continue for 14 days after the last positive blood culture, fungal peritonitis treatment is tied to catheter removal timing because the catheter itself is the primary source. 1, 3
- Prolonged treatment beyond 2 weeks after catheter removal to "determine response" is specifically discouraged in peritoneal dialysis fungal peritonitis. 1
- The mortality rate for fungal peritonitis ranges from 5-53%, and immediate catheter removal (within 24 hours) significantly reduces mortality compared to delayed removal (12.8% vs 31.7%). 4
Critical Management Points
Immediate Catheter Removal is Mandatory
- The catheter must be removed immediately upon identification of fungi by Gram stain or culture—this is non-negotiable. 1, 4
- Early catheter removal (within 24 hours) is independently associated with improved survival in multivariate analysis. 4
- All major guidelines emphasize that catheter retention in fungal peritonitis worsens outcomes. 5, 3
Antifungal Selection
- Fluconazole 200 mg daily is appropriate for hemodynamically stable patients without recent azole exposure. 3, 6
- For patients with recent fluconazole use or severe illness, echinocandins (caspofungin, micafungin, or anidulafungin) should be used instead. 6
- Prophylactic fluconazole during antibiotic treatment for bacterial peritonitis can reduce subsequent fungal peritonitis rates (from 7.8% to 4.0% in one quality control study). 7
When to Extend Beyond 2 Weeks
Do not extend antifungal therapy beyond 2 weeks after catheter removal unless there is documented persistent fungemia or metastatic infection. 2, 1
Extended treatment (4-6 weeks) is only indicated for:
- Persistent fungemia occurring >72 hours after catheter removal. 2, 5
- Evidence of metastatic infection (endocarditis, septic thrombophlebitis, endophthalmitis). 2, 5
- Documented deep tissue infection or osteomyelitis. 5
Monitoring Requirements
- Blood cultures should be obtained if systemic candidemia is suspected, and repeated every 24-48 hours until clearance is documented. 6
- Dilated ophthalmologic examination should be performed within the first week if candidemia is present to rule out endophthalmitis. 6
- Persistent fever or signs of infection beyond 72 hours after catheter removal warrant evaluation for metastatic infection. 2
Reinsertion Timing
- Attempts at peritoneal dialysis catheter reinsertion should only occur after waiting 4-6 weeks following catheter removal and completion of antifungal therapy. 1
- This waiting period allows adequate time for peritoneal healing and reduces risk of recurrent infection. 1
Common Pitfalls to Avoid
- Do not attempt catheter salvage with antifungal lock therapy in peritoneal dialysis fungal peritonitis—this approach is only appropriate for intravascular catheter-related candidemia, not peritoneal dialysis. 5, 1
- Do not continue antifungals indefinitely "to be safe"—this increases toxicity risk without evidence of benefit once the catheter is removed and the standard 10-14 day course is completed. 1
- Do not delay catheter removal to "see if antibiotics work first"—every day of delay increases mortality risk. 4