phuluong2k
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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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| nisha
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B.
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| mani
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C. Intravenous vancomycin. in case of CAPD associated peritonitis we first give a trial of antibiotics and if it fails to clear the infection only then we go for removal of catheter. Moreover empiric therapy usually is a combination of a cephalosporin and an aminoglycoside but i dont think an aminoglycoside alone would work
Edited by mani on 11/10/05 - 03:19 PM
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| chemamr
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C?
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| kabu
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Seems to be C
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| Dot
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B ) remove initialy the sourse of infection first n start t/t.I think its SBP(subacute bacterial peritonitis)
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| ARJ
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Its already discussed somewhere in the forum
Answer C
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| phuluong2k
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Peritonitis in a patient on CAPD is usually due to gram-positive pathogens such as Staphylococcus aureus or epidermidis. It is usually characterized by abdominal pain and over 100 white blood cells (typically polymorphonuclear leukocytes) in a sample of peritoneal dialysis fluid. Intravenous vancomycin would be a reasonable treatment to cover gram-positive pathogens.
Fluconazole (choice A) would be indicated for a fungal infection. Fungal peritonitis is not usually seen until patients have been treated with multiple antibiotics or are further immunosuppressed.
Immediate removal of the dialysis catheter (choice B) is usually not needed unless the patient has a peritonitis that has not improved with a trial of antibiotics.
Intravenous gentamicin (choice D) has good gram-negative coverage but would not be an ideal drug to cover Staphylococcus.
Ciprofloxacin (choice E) would be a very broad spectrum antibiotic that would not be a first choice as a single antibiotic to treat staphylococcal peritonitis. Further, the oral route may not be adequate as patients with peritonitis may have nausea and vomiting.
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