MDcooper
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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
[left] [/left]
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| robin082006
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B
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| mazinger
Forum Guru
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agree, but then what would be the antibiotic of choice between those listed?? oral cipro??
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| MDcooper
Forum Guru
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well the answer says it is peritonitis and in dialysis pt it is due to staph.so vanco is the answer given.
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| mazinger
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oh..... 
MD cooper extending things a little further could SPB be treated with oral cipro or other fluorquinolones like ofloxacin? I think I read that somewhere... Could anyone post a comment about this...
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| prathapdoctor
Forum Elite
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but in the question he is asking about most imp initial step in management,i think we have to give antibiotic therapy only after removing the dialysis catheter,but the answer is looking a bit contrast to previous theories.
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| r_albayunen
Forum Senior
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B .. i guess its futile to treat with antibiotics if the source of the peritonitis is still there. Ill go with B ..
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| MDcooper
Forum Guru
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The correct answer is C. 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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| fox
Forum Guru
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Thats pretty tough!
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| webjeee
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haha, Same USMLE Step 2 Practice Test as I have
internal medicine block1 q6
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