very high fever - zafirlukast

[ArchivalUser]

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

[ArchivalUser]

E. schedule emergent surgical removal of her Tesio catheter

[ArchivalUser]

B)

[ArchivalUser]

ans is B.
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.
Why not E??????
This may be indicated later in the course of care, but concern over removal before antibiotics have begun, is not appropriate.