03-04-2008, 12:39 AM
A 28-year-old patient with end-stage renal disease (ESRD) on continuous ambulatory
peritoneal dialysis (CAPD) for two months is brought to the emergency department 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
3
count of 14,200/mm , hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white
blood cells, 85% of which are polymorphonuclear leukocytes. Gram stain of the peritoneal fluid
is negative. Cultures of blood and peritoneal dialysis fluid are taken. Which of the following is
the most appropriate initial step in management?
1.Fluconazole
2.Immediate removal of dialysis catheter
3.Intravenous vancomycin
4.Intravenous gentamicin
5.Oral ciprofloxacin
peritoneal dialysis (CAPD) for two months is brought to the emergency department 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
3
count of 14,200/mm , hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white
blood cells, 85% of which are polymorphonuclear leukocytes. Gram stain of the peritoneal fluid
is negative. Cultures of blood and peritoneal dialysis fluid are taken. Which of the following is
the most appropriate initial step in management?
1.Fluconazole
2.Immediate removal of dialysis catheter
3.Intravenous vancomycin
4.Intravenous gentamicin
5.Oral ciprofloxacin