Chemotherapy and/or Removal of the Peritoneal Catheter in the Management of Fungal Peritonitis Complicating CAPD?

Emanuela Cecchin, MD, Unit of Nephrology and Dialysis, Hospital of Pordenone, I-33170 Pordenone (Italy) Dear Sir, Fungal peritonitis in patients undergoing peritoneal dialysis is gaining in importance because of its increasing frequency. Medical therapy remains a critical problem and so far has not been uniformly successful. Peritoneal catheter removal is, at present, the recommended method for its treatment [1, 2]. We read with interest the recent paper by Pocheville et al. [3] which reports a case of Candida peritonitis during chronic ambulatory peritoneal dialysis (CAPD) recovered with intraperitoneal administration of 5-fluorocytosine (5-FC) without removing the catheter. We report here our experience with this drug in the treatment of fungal peritonitis in patients on CAPD. Between 1980 and 1983 34 patients with end-stage renal disease were submitted to CAPD. There were 51 episodes of peritonitis 6% of which were caused by fungi predominantly of Candida and Torulopsis species. The strategy of therapy we used in patients with fungal peritonitis consisted in a protracted course of oral 5-FC with the Tenckhoff catheter left in situ [4]. The minimum inhibitory concentration of 5-FC against the etiologic agent was determined before starting therapy. It usually ranged between 0.1 and 1 μg/ml.5-FC was administered orally daily in a dose of 40 mg/kg body weight the first 2 days followed by 30 mg/kg daily for the next 2 days and then by a maintenance dose of 15 mg/kg daily for the remainder of the course of therapy. The drug was continued for 1 week after the dialysate leukocyte counts were normalized resulting approximately in a 5 week course of therapy. In 2 cases of peritonitis caused by Torulopsis glabrata we measured 5-FC levels in serum and peritoneal fluid [5]. In both cases the concentration of 5-FC in the peritoneal effluent ranged between 50 and 80 μg/ml well above the minimum inhibitory concentration of susceptible fungal strains. The drug was well tolerated in all patients and its serum peak levels never exceeded 100 μg/ml. Thus, our experience agreed with the current opinion that excess toxicity comes out only when serum levels exceed 100–125 μg/ml [6]. Medical management was successful in all cases with disappearance of symptoms and return of dialysate leukocyte counts to normal ( < 50/mm3) in 4 weeks. Dialysate cultures became sterile after 1–2 weeks of therapy but 5-FC treatment was continued for approximately 1 week after the return of dialysate leukocyte counts to normal in order to have a better probability of sterilization. In fact, there is recent evidence [7] that, though the findings from the cultures of peritoneal fluid became negative during therapy, catheters when removed were found to be heavily colonized by fungi. In