Aashi
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A 57-year old woman comes to the emergency department because of a "very high fever." She has diabetes mellitus and hemodialysis-dependent renal failure. She also has hypertension and is status-post total abdominal hysterectomy. She is frail appearing and diaphoretic. Her blood pressure is 170/90 mm Hg and temperature is 38.3 C (101.0 F). Her neck is supple without any specific meningismus. She has a Tesio catheter in her left subclavian vein. Her lungs are clear and she has no costovertebral angle tenderness. Her laboratory studies show a white blood cell count of 23,000/mm3 and a hematocrit of 31%. Her urinalysis is dipstick negative for white blood cells. The most appropriate next step in management is to
A. begin antibiotic therapy with gentamycin
B. begin antibiotic therapy with vancomycin and gentamycin
C. order urinalysis analysis and culture
D. perform a lumbar puncture and send CSF for analysis and culture
E. schedule emergent surgical removal of her Tesio catheter
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| sprint123
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Patients on hemodialysis is more prone for staphylococcus bacteremia. hence, in this patient, we could go in for Vancomycin as it could be used as a single dose per week due to renal failure. Since, it does not cover gram negative infection- Gentamycin is also added. Blood culture should be drawn initially before administration of antibiotics and if methiciillin-sensitive staph aureus is isolated, vancomycin could be changed to cephalosporins.
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| guangyu
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E
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| dr_gladiator
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It may be E.. as it may be infection due to cathetar.. so we need to remove cathetar first and take a swab from tip for culture and then start antibiotics..
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| dr.wad
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E
gentamycin is contraindicated in renal failure
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| cool doctor
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B
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| tamerbashir
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B
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| Aashi
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The correct answer is B.
Infection is the most common cause of death in patients with chronic renal failure. This is followed closely by cardiovascular events. The etiology of increased risk of infection is multifactorial and involves a complex interplay of decreased immune response and complement activation by dialysis membranes all coupled with long-term indwelling components such as catheters. When a dialysis patient presents with infection, the first step in their management is to initiate broad antibiotic coverage based upon the likely causative organisms. This patient has an indwelling catheter and therefore has an increased risk of infection with both coagulase-positive and coagulase-negative Gram-positive cocci. Given the large percentage (25% at most centers) of methicillin resistant Staphylococcus aureus (MRSA), vancomycin is usually initiated until sensitivity data is available. An aminoglycoside is usually added to cover for very common Gram-negative infections.
Begin antibiotic therapy with gentamicin (choice A) is inadequate since the majority of infections in patients such as these will not be covered by an aminoglycoside alone.
Sending her urine for analysis and culture (choice C), although prudent, to perform this with a negative urine dipstick for WBCs, will not change your initial management and decision to cover the patient with broad spectrum antibiotics.
Performing a lumbar puncture and sending a CSF for analysis and culture (choice D) implies meningitis as a cause for the fevers. Meningitis is a rare cause of fevers generally. And although dialysis patients are at mildly increased risk of meningeal infections, in the absence of localized signs and symptoms, the likelihood of meningitis is very low and therefore the risk of an LP is not warranted.
Schedule emergent surgical removal of her Tesio catheter (choice E) is not an appropriate initial management step in a febrile patient. This may be indicated later in the course of care, but concern over removal before antibiotics have begun, is not appropriate.
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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