Update on fungal peritonitis and its treatment

Fungal peritonitis (FP) is a rare but potentially fatal complication of chronic peritoneal dialysis (PD), associated with high morbidity and mortality ranging between 20% and 30%. If not leading to death, the inflammatory process usually causes irreversible damage to the peritoneal membrane with subsequent dropout from PD therapy. Fungal peritonitis accounts for 3% - 6% of all peritonitis episodes; however, in some areas, the numbers can be much higher. The most common cause of the disease is Candida, predominately C. albicans, C. parapsilosis, and-more recently- C. glabrata; other yeasts and filamentous fungi such as Aspergillus, Paecilomyces, Penicillium, and Zygomycetes are found, but much less frequently. The main factors associated with the development of FP include previous antibiotic therapy, particularly for bacterial peritonitis, when two important operative mechanisms coincide: fungal overgrowth in the gastrointestinal tract and declining peritoneal defense because of peritonitis. The management of FP poses a difficult challenge. Prompt initiation of therapy is critical, but no typical clinical picture has emerged, and the infecting organism can be difficult to isolate. The approach to the disease has changed considerably in recent years, and the 2005 guidelines from the International Society for Peritoneal Dialysis list FP as a strong indication for immediate catheter removal with temporary hemodialysis. The conventional antifungal regimens include fluconazole, amphotericin B, and flucytosine alone or in combination, optimally based on fungal sensitivities. The newer agents such as caspofungin and voriconazole have the potential to alter treatment strategies for FP, but further studies are required to clarify the precise role of these agents in this group of patients.