Our patient is a 67-year-old woman with a history of end-stage kidney disease due to obstructive uropathy from renal tuberculosis and prior left nephrectomy. She has a right sided percutaneous nephrostomy (PCN) tube that is exchanged every 3 - 4 months and has had several episodes of urinary tract infections associated with these exchanges. She was subsequently started on fluoroquinolone prophylaxis prior to PCN exchange with no infection in the past 2 years. She has been on PD for 12 years with no prior history of peritonitis. 
The patient presented to the emergency room 1 day after a routine colonoscopy with severe abdominal pain, right-flank tenderness, and cloudy urinary output from the PCN. She was started on empiric antibiotic therapy with intravenous (IV) vancomycin and meropenem. Peritoneal fluid studies were consistent with peritonitis with a nucleated cell count of 2,364 cells/muL. Peritoneal fluid culture grew E. coli resistant to ciprofloxacin, levofloxacin, tetracyclines, and trimethoprim-sulfamethoxazole. Urine culture from the PCN also grew E. coli. She was transitioned to intraperitoneal (IP) cefazolin with subsequent clinical improvement (812 cells/muL at day 4 of treatment). She was discharged with a 3-week course of IP ceftazidime. 
A week after completing the antibiotics, the patient presented to the PD clinic with recurrent symptoms of abdominal pain. PD fluid cultures revealed Gram-negative rods with a cell count of 1,109 cells/muL. Empiric treatment was started with ceftazidime and vancomycin. Culture studies showed Ralstonia species sensitive to gentamicin, tobramycin, cefepime, ciprofloxacin, amikacin, levofloxacin and resistant to ceftazidime, piperacillin/tazobactam. She was transitioned to IP cefepime and gentamicin for 3 weeks. Follow-up visits after the antibiotic course showed clinical improvement. 
Two weeks after completion of the antibiotics, she presented to the PD clinic again with abdominal pain, nausea, vomiting and diarrhea. The peritoneal fluid analysis done in clinic confirmed a third episode of peritonitis with a cell count of 846 cells/muL. The patient was immediately admitted with repeat peritoneal fluid analysis revealing a cell count of 2,910 cells/muL. Culture studies revealed Ralstonia mannitolilytica resistant to ceftazidime, piperacillin/tazobactam, aztreonam, ceftriaxone, cefepime, meropenem, gentamicin, and tobramycin. Recurrent infection with the same organism after prior antibiotic treatment raised the concern of PD catheter seeding of the organism. Hence, the PD catheter was removed, and the patient was started on hemodialysis and oral trimethoprim/sulfamethoxazole based on the sensitivities with subsequent clinical improvement.