A 64-year-old man comes to the emergency department after developing fever and chills during hemodialysis. He still feels feverish but has no sore throat, cough, abdominal pain, nausea, or diarrhea. Temperature was 38.9 C (102 F) at the dialysis center. The patient has a history of poorly controlled type 2 diabetes mellitus and hypertension, which led to end-stage renal disease. He was initiated on long-term intermittent hemodialysis 2 months ago. The patient has no known drug allergies. He does not use tobacco, alcohol, or illicit drugs. Temperature is 38 C (100.4 F) , blood pressure is 120/62 mm Hg, pulse is 105/min, and respirations are 22/min. Oxygen saturation is 96% on room air. There is a tunneled central venous catheter in the right internal jugular vein, and the skin around the insertion site is not erythematous or tender. Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds. The abdomen is soft and nontender. No skin rash or neck stiffness is present. Leukocyte count is 14,000/mm³ with 90% neutrophils. Chest-x ray reveals no infiltrate or consolidation. Two sets of blood cultures, one from a peripheral vein and the other from the central venous catheter, are obtained.
Which of the following is the most appropriate immediate next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient who has a tunneled hemodialysis catheter developed a fever with no localizing symptoms, raising suspicion for a catheter-related bloodstream infection (CRBSI). Tunneled hemodialysis catheters are associated with much higher rates of bacteremia (up to 2 episodes a year) than arteriovenous fistula. Most cases are caused by coagulase-negative staphylococci or Staphylococcus aureus, but infections with gram-negative bacilli are also common. Initial workup includes 2 sets of blood cultures, ideally one from a peripheral site and one from the central catheter. Empiric antibiotic therapy should then be initiated with vancomycin plus cefepime (or gentamicin). Catheter removal is indicated if any of the following are present: Severe sepsis Hemodynamic instability Evidence of metastatic infection (eg, endocarditis) Pus at the exit site of the catheter Continued symptoms after 72 hours of empiric antibiotics Long-term catheters (in place >14 days) should be removed if there is blood culture evidence of S aureus, Pseudomonas aeruginosa, or fungi (eg, Candida). Patients who do not require catheter removal should have the catheter changed over a guidewire (once afebrile and clinically stable if there is no evidence of tunnel tract involvement) or antibiotic lock therapy after each hemodialysis session. These measures are required to prevent recurrent infection. (Choices A and C) This patient requires the urgent initiation of empiric antibiotics to prevent morbidity and death. He has no indications for immediate catheter removal (eg, severe sepsis, hemodynamic instability, pus from the catheter site, evidence of metastatic infection). (Choice D) Vancomycin alone would not provide adequate coverage against gram-negative bacilli, and catheter change over a guidewire should be considered only once he is afebrile and clinically stable. (Choice E) The addition of empiric caspofungin is typically recommended for patients with CRBSI-related sepsis who have any of the following risk factors: Total parenteral nutrition, prolonged use of broad-spectrum antibiotics, hematological malignancy, solid organ transplant, femoral catheterization, or Candida colonization at multiple sites. Patients undergoing hemodialysis who develop CRBSI do not typically require empiric caspofungin coverage. Educational objective: Patients undergoing hemodialysis through a tunneled catheter have high rates of catheter-related bloodstream infection. Empiric treatment typically includes vancomycin plus cefepime (or gentamicin). Catheter removal is indicated for those with severe sepsis, hemodynamic instability, pus from the catheter site, evidence of metastatic infection, or symptoms that do not improve within 72 hours of antibiotic administration.

A 64-Year-Old Man Comes to the Emergency Department After Developing