A 54-year-old woman is brought to the emergency department due to fever. The patient has a history of end-stage kidney disease due to chronic glomerulonephritis and undergoes intermittent hemodialysis. Yesterday, after a dialysis session, she began experiencing malaise and chills. Overnight, she had high fever, chills, and rigors and became increasingly lethargic. There is no history of sore throat, cough, abdominal pain, or diarrhea. The patient's other medical conditions include sigmoid diverticulosis and asymptomatic gallstones. Temperature is 39 C (102.2 F), blood pressure is 84/52 mm Hg, pulse is 118/min, and respirations are 20/min. There is no erythema, purulence, or tenderness at the tunneled dialysis catheter insertion site. The lungs are clear on auscultation, and heart sounds are normal. The abdomen is soft and nontender. There is no extremity edema or skin rash. Laboratory studies reveal neutrophilic leukocytosis and elevated lactic acid level. Blood is drawn for culture; intravenous fluids and empiric broad-spectrum antibiotics are started via peripheral intravenous catheter. Chest x-ray shows no infiltrates. Which of the following additional interventions is most appropriate at this time?

Question

A 54-year-old woman is brought to the emergency department due to fever.  The patient has a history of end-stage kidney disease due to chronic glomerulonephritis and undergoes intermittent hemodialysis.  Yesterday, after a dialysis session, she began experiencing malaise and chills.  Overnight, she had high fever, chills, and rigors and became increasingly lethargic.  There is no history of sore throat, cough, abdominal pain, or diarrhea.  The patient's other medical conditions include sigmoid diverticulosis and asymptomatic gallstones.  Temperature is 39 C (102.2 F), blood pressure is 84/52 mm Hg, pulse is 118/min, and respirations are 20/min.  There is no erythema, purulence, or tenderness at the tunneled dialysis catheter insertion site.  The lungs are clear on auscultation, and heart sounds are normal.  The abdomen is soft and nontender.  There is no extremity edema or skin rash.  Laboratory studies reveal neutrophilic leukocytosis and elevated lactic acid level.  Blood is drawn for culture; intravenous fluids and empiric broad-spectrum antibiotics are started via peripheral intravenous catheter.  Chest x-ray shows no infiltrates.  Which of the following additional interventions is most appropriate at this time?

Quizplus · Accepted Answer

Patients undergoing hemodialysis through a tunneled dialysis catheter are at high risk for catheter-related bloodstream infection (CRBSI) due to migration of skin flora through the catheter lumen into the bloodstream. Because tunneled dialysis catheters have a cuff that prevents bacterial migration along the exterior of the catheter, patients with CRBSI usually have no evidence of infection around the external catheter site (eg, erythema, purulence). Therefore, most cases present with systemic signs of infection (eg, fever, chills, malaise) with no localizing manifestations to a particular region of the body. Progressive signs of shock (eg, lactic acidosis, confusion, hypotension) can occur rapidly due to bacteremia. Patients with suspected CRBSI require urgent blood cultures and hemodynamic support (in the setting of hypotension or shock). Empiric antibiotic therapy (eg, vancomycin plus ceftazidime) against common skin pathogens (eg, Staphylococcus aureus, coagulase-negative Staphylococcus) should be initiated without delay. Most patients then require prompt removal of the dialysis catheter to eliminate the nidus of infection and prevent persistent or progressive bacteremia. However, in some cases (eg, very poor access), antibiotic lock therapy may be used in lieu of dialysis catheter removal; the catheter is then exchanged over a guidewire several days later. (Choices A and E) This patient's abdominal examination is normal, and she has no symptoms localizing to the abdomen (eg, diarrhea, abdominal pain). Therefore, abdominal CT scan and right upper quadrant ultrasound are not indicated at this time; however, if the fever persists after removal of the dialysis catheter, additional imaging might be required to evaluate for another nidus of infection (eg, liver abscess). (Choice C) Intravenous glucocorticoids are sometimes used in patients with septic shock who do not adequately respond to fluid and vasopressor resuscitation after >1 hour of therapy. This patient does not have evidence of refractory shock; steroids should not be administered at this time because they can weaken the immune response to infection. (Choice D) A nuclear medicine bone scan can evaluate for occult osteomyelitis. This test may be required if the patient has persistent fever, bacteremia, and leukocytosis following removal of the dialysis catheter; however, it is not indicated at this time. Educational objective: Catheter-related bloodstream infections occur approximately once per year in patients with tunneled hemodialysis catheters. Most cases present with systemic signs of infection (eg, fever, malaise, chills) without localizing symptoms. The catheter site frequently appears normal. Initial therapy usually includes antibiotics, fluid resuscitation, and removal of the dialysis catheter.

A 54-Year-Old Woman Is Brought to the Emergency Department Due