Clostridioides difficile associated peritonitis in peritoneal dialysis patients – a case series based review of an under-recognized entity with therapeutic challenges

Abstract

Background: Initial presentation of peritoneal dialysis associated infectious peritonitis can be clinically indistinguishable from Clostridioides difficile infection (CDI) and both may demonstrate a cloudy dialysate. Empiric treatment of the former entails use of 3rd-generation cephalosporins, which could worsen CDI. We present a logical management approach of this clinical scenario providing examples of two cases with CDI associated peritonitis of varying severity where the initial picture was concerning for peritonitis and treatment for CDI resulted in successful cure. Case presentation: A 73-year-old male with ESRD managed with PD presented with fever, abdominal pain, leukocytosis and significant diarrhea. Cell count of the peritoneal dialysis effluent revealed 1050 WBCs/mm 3 with 71% neutrophils. C. difficile PCR on the stool was positive. Patient was started on intra-peritoneal (IP) cefepime and vancomycin for treatment of the peritonitis and intravenous (IV) metronidazole and oral vancomycin for treatment of the C. difficile colitis but worsened. PD fluid culture showed no growth. He responded well to IV tigecycline, oral vancomycin and vancomycin enemas. Similarly, a 55-year-old male with ESRD with PD developed acute diarrhea and on the third day noted a cloudy effluent from his dialysis catheter. PD fluid analysis showed 1450 WBCs/mm 3 with 49% neutrophils. IP cefepime and vancomycin were initiated. CT of the abdomen showed rectosigmoid colitis. C. difficile PCR on the stool was positive. IP cefepime and vancomycin were promptly discontinued. Treatment with oral vancomycin 125 mg every six hours and IV Tigecycline was initiated. PD fluid culture produced no growth. PD catheter was retained. Conclusions: In patients presenting with diarrhea with risk factors for CDI, traditional empiric treatment of PD peritonitis may need to be reexamined as they could have detrimental effects on CDI course and patient outcomes.

Clostridium difficile colitis and peritoneal dialysis associated peritonitis: ‘Difficile’ treatment considerations

“…tigecycline and discontinuation of board-spectrum intraperitoneal antibiotics, as a strategy that appropriately treat PD peritonitis, without potential worsening of CDI. 15 Tigecycline has a large broad activity and is an approved treatment of complex intra-abdominal infections. It has also proven in vitro efficacy against Clostridium difficile , 16 and there is increasing clinical data regarding its use alone or as a part of combination therapy for CDI, especially in severe cases.…”

Clostridioides difficile Infection in Chronic Kidney Disease—An Overview for Clinicians

“…In both cases, peritoneal dialysis-related peritonitis complicated by CDI and peritonitis caused by bacterial translocation, CDI patients will complain of abdominal pain, tenderness, nausea, vomiting and diarrhea, and the dialysate will be cloudy. The differentiation between these two conditions during the first days of infection depends mainly on the stool test for Clostridioides difficile toxins, as well as on the clinical resolution of the peritonitis symptoms after initiation of treatment dedicated to peritoneal dialysis-related peritonitis [ 40 , 41 ].…”

“…In the case that bacterial etiology of peritonitis is other than Clostridioides difficile, it is recommended to start antibiotic therapy in accordance with the obtained antibiotic susceptibility test results and to continue the current CDI pharmacotherapy. If Clostridioides difficile is cultured in a dialysis fluid sample or the microbiological culture result is negative, it is recommended to maintain the current pharmacotherapy with tigecycline and continue the current CDI pharmacotherapy [ 40 ].…”