bobby
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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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| bluestar
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B
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| chemamr
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B?
Please let me know the explanation of the right answer.
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| nisha
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B. don't wanna keep infusing infection
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| intern_doc
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B. rule of thumb....ALWAYS ...remove the source of infection FIRST...THEN START ANTIBIOTICS
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| bobby
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nope. i got it wrong chosing B like all you guys.
maybe this is an exception to that rule of thumb,
the correct ans given is C.
explanation was infection due to staph.
and if no respond, then B is the next thing to do
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| intern_doc
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NO really....????????/
We are all cant be that stupid ..LOL 
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| chemamr
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i knew that in this kind of disease you give antibiotics first, but i had the doubt that if itīs very toxic/severe, maybe removal. BUT I HAVE JUST CHECKED THE ANSWER IN HARRISON and:
most common causes are 1) Staph. epidermidis, 2) S. aureus
it says first you give intraperitoneal vancomyc + ampicillin and if doesnīt respond in 48 hours you remove the catheter.
So bobby, you are right, as almost always. Answer is C 
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| bobby
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good job chemamr for looking it up and resolving the doubt.
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if you haven't any charity in your heart, you have the worst kind of heart trouble.
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| chemamr
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thanks bobby 
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| tamar
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Yes, the answer is C. I think I saw the question about peritonitis in ESRD in Kaplan's Q-bank. First give IV vanco to cover gram-positive organisms. If not improved, remove the dialysis catheter.
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