{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,18]],"date-time":"2026-07-18T00:44:49Z","timestamp":1784335489035,"version":"3.55.0"},"reference-count":30,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2020,3,4]],"date-time":"2020-03-04T00:00:00Z","timestamp":1583280000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2020,3,4]],"date-time":"2020-03-04T00:00:00Z","timestamp":1583280000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000738","name":"U.S. Department of Veterans Affairs","doi-asserted-by":"publisher","award":["I01HX002639"],"award-info":[{"award-number":["I01HX002639"]}],"id":[{"id":"10.13039\/100000738","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000738","name":"U.S. Department of Veterans Affairs","doi-asserted-by":"publisher","award":["I01CX001661"],"award-info":[{"award-number":["I01CX001661"]}],"id":[{"id":"10.13039\/100000738","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Nephrol"],"published-print":{"date-parts":[[2020,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n<jats:title>Background<\/jats:title>\n<jats:p>Initial presentation of peritoneal dialysis associated infectious peritonitis can be clinically indistinguishable from <jats:italic>Clostridioides difficile<\/jats:italic> 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.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Case presentation<\/jats:title>\n<jats:p>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<jats:sup>3<\/jats:sup> with 71% neutrophils. <jats:italic>C. difficile<\/jats:italic> 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 <jats:italic>C. difficile<\/jats:italic> 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<jats:sup>3<\/jats:sup> with 49% neutrophils. IP cefepime and vancomycin were initiated. CT of the abdomen showed rectosigmoid colitis. <jats:italic>C. difficile<\/jats:italic> PCR on the stool was positive. IP cefepime and vancomycin were promptly discontinued. Treatment with oral vancomycin 125\u2009mg every six hours and IV Tigecycline was initiated. PD fluid culture produced no growth. PD catheter was retained.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Conclusions<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>","DOI":"10.1186\/s12882-020-01734-8","type":"journal-article","created":{"date-parts":[[2020,3,4]],"date-time":"2020-03-04T11:03:08Z","timestamp":1583319788000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Clostridioides difficile associated peritonitis in peritoneal dialysis patients \u2013 a case series based review of an under-recognized entity with therapeutic challenges"],"prefix":"10.1186","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6518-2683","authenticated-orcid":false,"given":"Kairav J.","family":"Shah","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kartikeya","family":"Cherabuddi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kalynn B.","family":"Pressly","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kaitlyn L.","family":"Wright","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashutosh","family":"Shukla","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2020,3,4]]},"reference":[{"issue":"5","key":"1734_CR1","doi-asserted-by":"publisher","first-page":"481","DOI":"10.3747\/pdi.2016.00078","volume":"36","author":"PK Li","year":"2016","unstructured":"Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int : J Int Soc Perit Dial. 2016;36(5):481\u2013508.","journal-title":"Perit Dial Int : J Int Soc Perit Dial"},{"issue":"4","key":"1734_CR2","doi-asserted-by":"publisher","first-page":"967","DOI":"10.1038\/ki.1992.375","volume":"42","author":"FK Port","year":"1992","unstructured":"Port FK, Held PJ, Nolph KD, Turenne MN, Wolfe RA. Risk of peritonitis and technique failure by CAPD connection technique: a national study. Kidney Int. 1992;42(4):967\u201374.","journal-title":"Kidney Int"},{"key":"1734_CR3","doi-asserted-by":"publisher","first-page":"187","DOI":"10.1159\/000093594","volume":"150","author":"I Teitelbaum","year":"2006","unstructured":"Teitelbaum I. Cloudy peritoneal dialysate: it's not always infection. Contrib Nephrol. 2006;150:187\u201394.","journal-title":"Contrib Nephrol"},{"issue":"1","key":"1734_CR4","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1046\/j.1525-139x.2001.00012.x","volume":"14","author":"MA Rocklin","year":"2001","unstructured":"Rocklin MA, Teitelbaum I. Noninfectious causes of cloudy peritoneal\u2003dialysate. Semin Dial. 2001;14(1):37\u201340.","journal-title":"Semin Dial"},{"issue":"5","key":"1734_CR5","doi-asserted-by":"publisher","first-page":"431","DOI":"10.1086\/651706","volume":"31","author":"SH Cohen","year":"2010","unstructured":"Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431\u201355.","journal-title":"Infect Control Hosp Epidemiol"},{"key":"1734_CR6","unstructured":"Frequently asked questions about Clostridium difficile for healthcare providers [https:\/\/www.cdc.gov\/hai\/organisms\/cdiff\/cdiff_clinicians.html]. Accessed 06\/16\/2019."},{"key":"1734_CR7","first-page":"63","volume":"7","author":"A Gupta","year":"2014","unstructured":"Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infect Drug Resist. 2014;7:63\u201372.","journal-title":"Infect Drug Resist"},{"issue":"10","key":"1734_CR8","doi-asserted-by":"publisher","first-page":"2913","DOI":"10.1007\/s10620-015-3714-9","volume":"60","author":"P Phatharacharukul","year":"2015","unstructured":"Phatharacharukul P, Thongprayoon C, Cheungpasitporn W, Edmonds PJ, Mahaparn P, Bruminhent J. The risks of incident and recurrent Clostridium difficile-associated diarrhea in chronic kidney disease and end-stage kidney disease patients: a systematic review and meta-analysis. Dig Dis Sci. 2015;60(10):2913\u201322.","journal-title":"Dig Dis Sci"},{"issue":"2","key":"1734_CR9","doi-asserted-by":"publisher","first-page":"353","DOI":"10.1136\/jim-2016-000183","volume":"65","author":"A Tirath","year":"2017","unstructured":"Tirath A, Tadros S, Coffin SL, Kintziger KW, Waller JL, Baer SL, Colombo RE, Huber LY, Kheda MF, Nahman NS Jr. Clostridium difficile infection in dialysis patients. J Invest Med : Official Publ Am Fed Clini Res. 2017;65(2):353\u20137.","journal-title":"J Invest Med : Official Publ Am Fed Clini Res"},{"issue":"2","key":"1734_CR10","doi-asserted-by":"publisher","first-page":"136","DOI":"10.1111\/1469-0691.12221","volume":"20","author":"F Barbut","year":"2014","unstructured":"Barbut F, Surgers L, Eckert C, Visseaux B, Cuingnet M, Mesquita C, Pradier N, Thiriez A, Ait-Ammar N, Aifaoui A, et al. Does a rapid diagnosis of Clostridium difficile infection impact on quality of patient management? Clin Microbiol Infect : Official Publ Eur Soc Clin Microbiol Infect Dis. 2014;20(2):136\u201344.","journal-title":"Clin Microbiol Infect : Official Publ Eur Soc Clin Microbiol Infect Dis"},{"issue":"12","key":"1734_CR11","doi-asserted-by":"publisher","first-page":"3945","DOI":"10.1128\/JCM.02021-15","volume":"53","author":"S Bharti","year":"2015","unstructured":"Bharti S, Malhotra P, Juretschko S. Successful treatment of peritoneal Dialysis catheter-related Polymicrobial peritonitis involving <span class=\"named-content genus-species\" id=\"named-content-1\">Clostridium difficile<\/span>. J Clin Microbiol. 2015;53(12):3945\u20136.","journal-title":"J Clin Microbiol"},{"issue":"10","key":"1734_CR12","doi-asserted-by":"publisher","first-page":"1028","DOI":"10.1016\/j.ajic.2014.06.011","volume":"42","author":"KR Reveles","year":"2014","unstructured":"Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010. Am J Infect Control. 2014;42(10):1028\u201332.","journal-title":"Am J Infect Control"},{"issue":"1","key":"1734_CR13","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1038\/ajg.2011.398","volume":"107","author":"S Khanna","year":"2012","unstructured":"Khanna S, Pardi DS, Aronson SL, Kammer PP, Orenstein R, St Sauver JL, Harmsen WS, Zinsmeister AR. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am J Gastroenterol. 2012;107(1):89\u201395.","journal-title":"Am J Gastroenterol"},{"issue":"4","key":"1734_CR14","doi-asserted-by":"publisher","first-page":"471","DOI":"10.1111\/j.1440-1797.2009.01274.x","volume":"15","author":"R Eddi","year":"2010","unstructured":"Eddi R, Malik MN, Shakov R, Baddoura WJ, Chandran C, Debari VA. Chronic kidney disease as a risk factor for Clostridium difficile infection. Nephrology (Carlton, Vic). 2010;15(4):471\u20135.","journal-title":"Nephrology (Carlton, Vic)"},{"issue":"5","key":"1734_CR15","doi-asserted-by":"publisher","first-page":"1248","DOI":"10.1086\/516960","volume":"25","author":"MC Laroche","year":"1997","unstructured":"Laroche MC, Alfa MJ, Harding GKM. Isolation of toxigenic Clostridium difficile from dialysate fluid in a fatal case of chronic ambulatory peritoneal Dialysis-related peritonitis. Clin Infect Dis. 1997;25(5):1248.","journal-title":"Clin Infect Dis"},{"issue":"3","key":"1734_CR16","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1016\/S0163-4453(86)91190-4","volume":"13","author":"I Brook","year":"1986","unstructured":"Brook I, Walker RI. Pathogenicity of Clostridium species with other bacteria in mixed infections. J Infect. 1986;13(3):245\u201353.","journal-title":"J Infect"},{"issue":"1","key":"1734_CR17","doi-asserted-by":"publisher","first-page":"139","DOI":"10.3747\/pdi.2012.00177","volume":"34","author":"T Arikan","year":"2014","unstructured":"Arikan T, Unal A, Kocyigit I, Yurci A, Oymak O. Peritoneal Dialysis-related peritonitis triggered by Clostridium difficile-associated colitis. Perit Dial Int : J Int Soc Perit Dial. 2014;34(1):139\u201340.","journal-title":"Perit Dial Int : J Int Soc Perit Dial"},{"issue":"1","key":"1734_CR18","first-page":"130","volume":"34","author":"JJ Ribes-Cruz","year":"2014","unstructured":"Ribes-Cruz JJ, Gonzalez-Rico M, Juan-Garcia I, Puchades-Montesa MJ, Torregrosa-Maicas I, Ramos-Tomas C, Solis-Salguero MA, Tomas-Simo P, Tejedor-Alonso S, Zambrano-Esteves P, et al. Cloudy peritoneal effluent and diarrhoea due to Clostridium difficile. Nefrol : Publ oficial de la Soc Esp Nefrol. 2014;34(1):130\u20131.","journal-title":"Nefrol : Publ oficial de la Soc Esp Nefrol"},{"issue":"9","key":"1734_CR19","doi-asserted-by":"publisher","first-page":"920","DOI":"10.1016\/j.lfs.2005.05.102","volume":"78","author":"G Canny","year":"2006","unstructured":"Canny G, Drudy D, Macmathuna P, O'Farrelly C, Baird AW. Toxigenic C. difficile induced inflammatory marker expression by human intestinal epithelial cells is asymmetrical. Life Sci. 2006;78(9):920\u20135.","journal-title":"Life Sci"},{"issue":"2","key":"1734_CR20","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1177\/089686080402400204","volume":"24","author":"T Liberek","year":"2004","unstructured":"Liberek T, Chmielewski M, Lichodziejewska-Niemierko M, Lewandowski K, Rutkowski B. Transmigration of blood leukocytes into the peritoneal cavity is related to the upregulation of ICAM-1 (CD54) and mac-1 (CD11b\/CD18) adhesion molecules. Perit Dial Int : J Int Soc Perit Dial. 2004;24(2):139\u201346.","journal-title":"Perit Dial Int : J Int Soc Perit Dial"},{"issue":"12","key":"1734_CR21","doi-asserted-by":"publisher","first-page":"1067","DOI":"10.1111\/j.1469-0691.2009.03099.x","volume":"15","author":"MP Bauer","year":"2009","unstructured":"Bauer MP, Kuijper EJ, van Dissel JT. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance document for Clostridium difficile infection (CDI). Clin Microbiol Infect : Official Publ Eur Soc Clin Microbiol Infect Dis. 2009;15(12):1067\u201379.","journal-title":"Clin Microbiol Infect : Official Publ Eur Soc Clin Microbiol Infect Dis"},{"issue":"1","key":"1734_CR22","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1186\/s13017-019-0228-3","volume":"14","author":"M Sartelli","year":"2019","unstructured":"Sartelli M, Di Bella S, McFarland LV, Khanna S, Furuya-Kanamori L, Abuzeid N, Abu-Zidan FM, Ansaloni L, Augustin G, Bala M, et al. 2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients. World J Emerg Surg. 2019;14(1):8.","journal-title":"World J Emerg Surg"},{"issue":"5","key":"1734_CR23","doi-asserted-by":"publisher","first-page":"562","DOI":"10.1177\/089686080802800528","volume":"28","author":"Y Sakao","year":"2008","unstructured":"Sakao Y, Kato A, Sugiura T, Fujikura T, Misaki T, Tsuji T, Sakakima M, Yasuda H, Fujigaki Y, Hishida A. Cloudy dialysate and pseudomembranous colitis in a patient on CAPD. Perit Dial Int : J Int Soc Perit Dial. 2008;28(5):562\u20133.","journal-title":"Perit Dial Int : J Int Soc Perit Dial"},{"issue":"Suppl 2","key":"1734_CR24","doi-asserted-by":"publisher","first-page":"ii25","DOI":"10.1093\/jac\/dkt142","volume":"68","author":"C Eckmann","year":"2013","unstructured":"Eckmann C, Montravers P, Bassetti M, Bodmann KF, Heizmann WR, Sanchez Garcia M, Guirao X, Capparella MR, Simoneau D, Dupont H. Efficacy of tigecycline for the treatment of complicated intra-abdominal infections in real-life clinical practice from five European observational studies. J Antimicrob Chemother. 2013;68(Suppl 2):ii25\u201335.","journal-title":"J Antimicrob Chemother"},{"key":"1734_CR25","doi-asserted-by":"publisher","first-page":"88","DOI":"10.1186\/1471-2334-5-88","volume":"5","author":"ME Oliva","year":"2005","unstructured":"Oliva ME, Rekha A, Yellin A, Pasternak J, Campos M, Rose GM, Babinchak T, Ellis-Grosse EJ, Loh E. A multicenter trial of the efficacy and safety of tigecycline versus imipenem\/cilastatin in patients with complicated intra-abdominal infections [Study ID Numbers: 3074A1\u2013301-WW; ClinicalTrials.gov Identifier: NCT00081744]. BMC Infect Dis. 2005;5:88.","journal-title":"BMC Infect Dis"},{"issue":"3","key":"1734_CR26","doi-asserted-by":"publisher","first-page":"228","DOI":"10.3109\/00365548.2011.616224","volume":"44","author":"RI El-Herte","year":"2012","unstructured":"El-Herte RI, Baban TA, Kanj SS. Recurrent refractory Clostridium difficile colitis treated successfully with rifaximin and tigecycline: a case report and review of the literature. Scand J Infect Dis. 2012;44(3):228\u201330.","journal-title":"Scand J Infect Dis"},{"issue":"12","key":"1734_CR27","doi-asserted-by":"publisher","first-page":"1732","DOI":"10.1086\/599224","volume":"48","author":"BL Herpers","year":"2009","unstructured":"Herpers BL, Vlaminckx B, Burkhardt O, Blom H, Biemond-Moeniralam HS, Hornef M, Welte T, Kuijper EJ. Intravenous tigecycline as adjunctive or alternative therapy for severe refractory Clostridium difficile infection. Clin Infect Dis : Official Publ Infect Dis Soc Am. 2009;48(12):1732\u20135.","journal-title":"Clin Infect Dis : Official Publ Infect Dis Soc Am"},{"issue":"1","key":"1734_CR28","doi-asserted-by":"crossref","first-page":"ofw264","DOI":"10.1093\/ofid\/ofw264","volume":"4","author":"LS MT","year":"2017","unstructured":"MT LS, Branch-Elliman W, Snyder GM, Mahoney MV, Alonso CD, Gold HS, Wright SB. Does Adjunctive Tigecycline Improve Outcomes in Severe-Complicated, Nonoperative Clostridium difficile Infection? Open Forum Infect Dis. 2017;4(1):ofw264.","journal-title":"Open Forum Infect Dis"},{"issue":"1","key":"1734_CR29","doi-asserted-by":"publisher","first-page":"201","DOI":"10.1186\/s12879-018-3103-z","volume":"18","author":"J Lin","year":"2018","unstructured":"Lin J, Wang R, Chen J. Tigecycline-induced acute pancreatitis in a renal transplant patient: a case report and literature review. BMC Infect Dis. 2018;18(1):201.","journal-title":"BMC Infect Dis"},{"key":"1734_CR30","unstructured":"Tygacil (tigecycline) iv injection label \u2013 FDA [https:\/\/www.accessdata.fda.gov\/drugsatfda_docs\/label\/2013\/021821s026s031lbl.pdf]. Accessed 16 June 2019."}],"container-title":["BMC Nephrology"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12882-020-01734-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1186\/s12882-020-01734-8\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12882-020-01734-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,3,4]],"date-time":"2021-03-04T00:17:26Z","timestamp":1614817046000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcnephrol.biomedcentral.com\/articles\/10.1186\/s12882-020-01734-8"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,3,4]]},"references-count":30,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2020,12]]}},"alternative-id":["1734"],"URL":"https:\/\/doi.org\/10.1186\/s12882-020-01734-8","relation":{},"ISSN":["1471-2369"],"issn-type":[{"value":"1471-2369","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,3,4]]},"assertion":[{"value":"18 July 2019","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"19 February 2020","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 March 2020","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"No ethical approval was required for this case report. Written informed consent was obtained from the patients.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Written informed consent was obtained from the patients for publication of this case report. A copy of the written consent is available for review.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"All authors report no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"76"}}