Successful Treatment of Peritoneal Dialysis Catheter-Related Polymicrobial Peritonitis Involving Clostridium difficile

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

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/mm3 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/mm3 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 Ramosum-A Rare Cause of Peritoneal Dialysis-Related Peritonitis

We present the first report of a patient with peritoneal dialysis (PD)-related peritonitis due to Clostridium ramosum, an anaerobe bacterium that is commonly found in normal fecal flora. On rare occasions, it can be pathogenic in immunocompromised individuals. Clostridium species, including Clostridium ramosum, should be included in the differential diagnosis of PD-related peritonitis.

Secondary bacterial peritonitis and pelvic abscess due to Clostridium difficile

A 70-year-old man with a history of hepatic cirrhosis presented with abdominal discomfort and distention. Physical examination revealed abdominal distention, positive fluid wave and abdominal tenderness. Due to concerns for spontaneous bacterial peritonitis (SBP), paracentesis was performed. Fluid analysis revealed 5371 total nucleated cells with 48% neutrophils. Ceftriaxone was then initiated for the treatment of SBP. Bacterial cultures of the fluid, however, grew Clostridium difficile Therefore, metronidazole was added. An abdominal ultrasound revealed a pelvic fluid collection that was suspicious for an abscess on an abdominal CT scan. The patient underwent CT-guided drain placement into the pelvic fluid collection. The fluid aspirate was consistent with an abscess. However, cultures were negative in the setting of ongoing antibiotic therapy. The patient was treated with a 10-day course of ceftriaxone and metronidazole and was discharged home with outpatient follow-up.

Clostridium difficile Peritonitis: An Emerging Infection in Peritoneal Dialysis Patients

Recently, the incidence of Clostridium difficile- (C. difficile-) associated infection has increased significantly in hospital and ambulatory care settings in parallel to the increasing use of inappropriate antibiotics. According to the CDC, approximately 83,000 patients who developed C. difficile experienced at least one recurrence and 29,000 died within 30 days of the initial diagnosis. Patients on dialysis (particularly peritoneal dialysis) are predisposed to this infection due to an inherent immunocompromised state and transmural translocation of the bacteria due to the close association of gastrointestinal tract and peritoneal cavity. C. difficile infection in peritoneal dialysis patients is problematic from two aspects: (1) because dialysis patients are immunocompromised, the infection can be devastating and (2) infection directly interferes with their renal replacement therapy. In this article, we present a case of peritoneal dialysis (PD)-related peritonitis caused by C. difficile-associated diarrhea and colitis. In this patient, the peritonitis was caused by transmural translocation of the enteric bacteria. While the peritoneal fluid culture did not grow the organism (possibly because of prior empiric broad-spectrum antibiotics use), the positive PCR on stool analysis suggested C. difficile-related peritonitis, along with the rapid clinical improvement induced by C. difficile-directed therapy (metronidazole) and discontinuation of broad-spectrum antibiotics. The patient was successfully treated with metronidazole without PD catheter removal. C. difficile infection is common and frequently internists are the first contact with such patients. This article highlights C. difficile infection in a PD patient and raises awareness of this infection in dialysis patients.