Version July 2025
KOH: potassium hydroxide.
* Fungal organisms may be identified by Gram stain or specific fungal stains (eg, KOH or calcofluor white stains), but a negative stain does not rule out fungal infection.
¶ Catheter removal is indicated in all cases of fungal peritonitis and has been associated with improved outcomes, including mortality.
Δ Antifungal therapy should begin as soon as peritoneal fluid reveals a fungus by stain or culture and should not be delayed for catheter removal or peritoneal lavage. For patients who have had recent antifungal exposure, we avoid that antifungal class until susceptibility results return.
◊ The microbiology laboratory can usually provide clarification of whether a fungal isolate is a yeast or a mold.
§ For most patients with mold infection, we use intravenous amphotericin B deoxycholate. We use liposomal amphotericin B if a patient has residual kidney function or severe infusion-related reactions, or the deoxycholate formulation is unavailalbe. Consultation with an infectious diseases expert is recommended for all mold infections.
¥ For all Candida isolates, we request susceptibility testing for fluconazole, voriconazole, and an echinocandin (eg, micafungin, caspofungin, anidulofungin).
‡ Amphotericin B has traditionally been used for treatment of azole-resistant candidal peritonitis. Echinocandins have proven efficacy for treatment of peritoneal infections unrelated to peritoneal dialysis, but experience in peritoneal dialysis-associated fungal peritonitis is limited.
† Oral azoles achieve high blood levels, so intravenous azole admininstration for initial management is typically unnecessary except for patients who have poor gastrointestinal absorption.