Peritoneal dialysis associated peritonitis and Clostridioides difficile infection: Association or different entities?

Peritoneal dialysis (PD) associated peritonitis is a common complication and main cause of PD failure among end-stage chronic kidney disease (CKD) patients, presenting with abdominal pain, diarrhea and cloudy dialysate. On the other side, these patients may have an increased risk for Clostridioides difficile infection (CDI), with a clinical presentation indistinguishable from PD associated peritonitis. We present the case of a female patient who presented with multiple episodes of watery diarrhea days after PD catheter insertion, treated initially as a suspected PD associated peritonitis but later identifying C. difficile toxin assay in stool and responding with triple therapy including oral vancomycin, metronidazole and tigecycline. Considering the scarce evidence, we conducted a literature search and identified 10 case reports involving 11 patients describing CDI associated peritonitis in patients with PD. Most cases initiated empiric intraperitoneal treatment for PD associated peritonitis but after lack of clinical improvement or increase in PD fluid cell count, and a positive C. difficile toxin assay in stool, treatment for CDI was started. Half of these patients had received prior antibiotic therapy or had a prior hospital admission. In conclusion, patients with PD associated peritonitis unresponsive to initial empiric intraperitoneal treatment should be tested for C. difficile in stool, especially those with previous antibiotic exposure or hospital admission.