indlaxman
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A 28-year-old patient with end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD) for two months presents with fever, abdominal pain and cloudy dialysis fluid. There is no diarrhea or vomiting and the pain has been present for about 12 hours. The patient has ESRD secondary to chronic glomerulonephritis, there is no history of diabetes, urinary infections or antibiotic use. Examination reveals a temperature of 38.9 C (102 F), and blood pressure of 110/70 mm Hg. The throat is clear, as are the lungs. Cardiac examination reveals a grade 2/6 systolic murmur. Abdominal examination reveals decreased bowel sounds with diffuse tenderness. There is mild rebound. There is no edema or skin rash. A complete blood count shows a leukocyte count of 14,200/mm3, hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white blood cells, 85% of which are polymorphonuclear leukocytes. Gram's stain of fluid is negative. Cultures of blood and peritoneal dialysis fluid are taken. Which of the following is the most appropriate initial step in management?
A. Fluconazole
B. Immediate removal of dialysis catheter.
C. Intravenous vancomycin
D.Intravenous gentamicin
E.Oral ciprofloxacin
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| crista
Forum Guru
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vancomycin seems to be the treat. bz usually the germ is staf. -only my oppinion
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| miky
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A 28-year-old patient with end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD) for two months presents with fever, abdominal pain and cloudy dialysis fluid. There is no diarrhea or vomiting and the pain has been present for about 12 hours. The patient has ESRD secondary to chronic glomerulonephritis, there is no history of diabetes, urinary infections or antibiotic use. Examination reveals a temperature of 38.9 C (102 F), and blood pressure of 110/70 mm Hg. The throat is clear, as are the lungs. Cardiac examination reveals a grade 2/6 systolic murmur. Abdominal examination reveals decreased bowel sounds with diffuse tenderness. There is mild rebound. There is no edema or skin rash. A complete blood count shows a leukocyte count of 14,200/mm3, hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white blood cells, 85% of which are polymorphonuclear leukocytes. Gram's stain of fluid is negative. Cultures of blood and peritoneal dialysis fluid are taken. Which of the following is the most appropriate initial step in management?
A. Fluconazole
B. Immediate removal of dialysis catheter.
C. Intravenous vancomycin
D.Intravenous gentamicin
E.Oral ciprofloxacin
So, let's see:
In my opinion this is a clear catheter associated infections. And as in any such case, the first step is to remove the catheter and replace it wit another one. So, the answer is B.
Further, the GS of the fluid is negative, but PMN leukocytes predominate in the fluid. So, if no bacteria seen, it's probably either fungi or TB. Since anti-TB drugs are not an option, fungi are probably the most logical presence in the fluid. So, I would give Fluconazole.
But, as I said, remove catheter first (it's illogical to leave it in place) and give antimicrobials then.
My opinion.
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| crista
Forum Guru
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removing the catheter is not an option, you are doing this only when the infection can be resolved with Ab.
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| miky
Forum Senior
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First, in any catheter-associated infection, the first step is to remove the infected catheter. Bacteria / fungi adhere to the catheter making a microfilm which is, in most cases, impenetratble to ABs and the common source of persisting infection.
Second, I've run into a serious dilema.
Gram's stain of fluid is negative - what do you mean by that?????
Is it: negative GS or no bacteria seen on GS?
Pls explain.
If negative GS - iv gentamicin is the correct answer, but only after catheter removal.
If no bacteria seen on GS, then see the answer I gave in a previous postmail.
Also, have the decency to give the correct answer, pls :roll: . Posting a case on this site w/o an answer will not benefit any of us. My opinion  .
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| collins
Forum Senior
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B.
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| lucky
Forum Guru
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seems like gram -ve perotinitis to me. i would go for iv gentamycin.
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| mash
Forum Fanatic
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iv vancomycin
hx of fever, abd pain/ tenderness and mild rebound
leukocytosis of 1000 in cloudy peritoneal fluid with>75% neutrophils--->sp. bacterial peritonitis
most common comp of CAPD is peritonitis and mc org is staph aureus.
negative gram stain means no organisms identified on gram stain
gentamicin is nephrotoxic
so, iv vancomycin can be used
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| yutaro
Forum Newbie
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This is a common problem for patients recieving peritoneal dialysis.
I expeienced the young male CRF patient with peritonitis.
First of all, removal of catheter is important. Secondly, to do is washing his peritineal cavity many times with clean fluids ,sometimes containing ABs. Thirdly, folow up the cell counts.
so the answer is B.
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