Fungal Peritoneal Dialysis (PD) Peritonitis Managed with Simultaneous PD Catheter Removal and New PD Catheter Insertion

Introduction: Guidelines for management of fungal PD peritonitis include PD catheter removal and switch to hemodialysis. Here we present a case where we removed the old PD catheter removal and placed a new PD catheter due to patient's wish to avoid hemodialysis Case Description: This case is of a 46 year old female with a history of ESRD secondary to IgA nephropathy on peritoneal dialysis (PD) and failed renal transplant, as well as a history of Staph A (penicillin resistant) peritonitis who initially presented to outpatient clinic with cloudly PD effluent and abdominal pain. PD fluid cultures and cell count was obtained after which she was started on empiric IP antimicrobials. Her culture returned positive for yeast, after which she was recommended for hospital admission. In the hospital, she was started on IV micafungin and IP fluconazole, and continued on empiric IP antibiotics. She was recommended by her nephrologist for PD catheter removal and switch to HD, however the patient did not want to do HD even if it resulted in worsening clinical progression or death. Therefore after many discussions, she was planned for and underwent PD catheter removal and placement of new PD catheter. She was continued on IV micafungin and IP fluconazole, while IP antibiotics switched to IV antibiotics. PD fluid cell count and cultures were taken daily. Nucleated cell count peaked at 1650, then decreased to 1 throughout hospital course and with antimicrobials. Her fungal culture grew aureobasidium pullulans. With input from infectious disease team, her micafungin was changed to IV amphotericin B. She was then started on urgent start PD protocol in the hospital. Subsequent cultures also grew psuedomonas putida and fluorenscens (both sensitive to ceftazidime and levaquin). She was discharged with tunneled PICC line for IV amphotericin for 4 week course. She was continued on IP ceftazidime and oral levofloxacin for 3 weeks after negative fluid cultures. Discussion: This case is unique in management, as our patient was firmly against starting hemodialysis, even after lengthy discussions involving risk of treatment failure and death. Therefore, to keep the patient's wishes to continue with PD and avoid HD, we had to alter the management plan. In this case, we were able successfully treat fungal peritonitis and do urgent start PD with removal of the old PD catheter and placement new PD catheter.