Case 24 Index
Vital Signs: Temperature 98.5 °F, Blood Pressure 130/95 mmHg, Heart Rate 82 beats/min, Respiratory Rate 14 breaths/min
General Appearance: thin, in no acute distress
HEENT: clear oropharynx, sclera anicteric, mucous membranes moist
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythm, no rubs/murmurs/gallops
Pulmonary: Breath sounds normal bilaterally, no rales/rhonchi/wheezes
Abdominal: soft, non-tender, non-distended
Extremities: warm and well perfused, +1 pitting edema to shin bilaterally
Back: fullness of both flanks, no costovertebral angle (CVA) tenderness, no spinal tenderness
Neurologic: awake, alert, and answers appropriately
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rash
Let’s examine the dialysis access.
Tenderness and erythema are noted over the subcutaneous tunnel of the dialysis catheter 4 cm from the exit site. Manual compression over the tunnel site reveals the following (click)
The microbiology lab calls and reports that the blood cultures are growing an organism, but the gram stain and speciation are still pending.
What would you do next?
While awaiting the blood culture results, treat empirically with antibiotics to cover gram-positive organisms for 7-14 days, then repeat the blood cultures.
This is not the best management for this patient, given the physical examination findings. Try again!
While awaiting the blood culture results, treat empirically with antibiotics to cover both gram-positive and gram-negative organisms for 7-14 days, then repeat the blood cultures.
This is not the best management for this patient, given the physical examination findings. Try again!
Apply a topical antimicrobial to the exit site and instill an antimicrobial lock.
These are prophylactic measures that may reduce the incidence of catheter-related blood stream infections, but are unlikely to be helpful here. Pick again!
While awaiting the blood culture results, treat empirically with antibiotics to cover both gram-positive and gram-negative organisms and immediately refer the patient for tunneled dialysis catheter removal.
Yes! A patient with CRBSI and a tunnel infection should be treated with systemic antimicrobial therapy and be referred for catheter removal.
While awaiting the blood culture results, treat empirically with antibiotics to cover both gram-positive and gram-negative organisms and immediately refer the patient for tunneled dialysis catheter exchange over a guide wire.
This approach may lead to a recurrent infection. Pick again!
Click here to move on!
Case 24 Index
Case 24 Introduction
