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. 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. 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.

中文翻译：

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腹膜透析患者难治性梭状芽胞杆菌相关性腹膜炎-基于病例系列的回顾研究缺乏认识，并面临治疗挑战。

腹膜透析相关的感染性腹膜炎的最初表现在临床上与艰难梭菌（Clostridioides difficile）感染（CDI）在临床上无法区分，并且两者都可能显示出浑浊的透析液。对前者的经验性治疗需要使用第三代头孢菌素，这可能会使CDI恶化。我们提供了一种针对这种临床情况的逻辑管理方法，提供了两个严重程度不同的CDI相关性腹膜炎病例的示例，这些病例最初涉及的是腹膜炎，而CDI的治疗成功治愈了。一名73岁的ESRD男性，经PD治疗后出现发烧，腹痛，白细胞增多和严重腹泻。腹膜透析流出物的细胞计数显示1050 WBCs / mm3，中性粒细胞为71％。粪便上的艰难梭菌PCR为阳性。患者开始接受腹膜内（IP）头孢吡肟和万古霉素治疗腹膜炎，并开始使用静脉内（IV）甲硝唑和口服万古霉素治疗艰难梭菌结肠炎，但病情恶化。PD液体培养显示无生长。他对IV替加环素，口服万古霉素和万古霉素灌肠剂反应良好。同样，一名55岁，患有ESRD，PD的男性也出现了急性腹泻，在第三天，他的透析导管流出物浑浊。PD液体分析显示1450 WBC / mm3，中性粒细胞为49％。IP头孢吡肟和万古霉素开始使用。腹部CT显示为乙状结肠炎。粪便上的艰难梭菌PCR为阳性。立即停用IP头孢吡肟和万古霉素。每六个小时用125 mg万古霉素口服治疗，并开始静脉注射Tigecycline。PD液体培养无生长。保留PD导管。对于腹泻而有CDI危险因素的患者，可能需要重新检查传统的PD腹膜炎经验治疗，因为它们可能对CDI进程和患者预后产生不利影响。