Re-insert subclavian vein catheter and discharge patient on four weeks of antibiotic therapy
CT angiogram of the right subclavian vein
Ans. A. Echocardiogram
This patient on hemodialysis through an intravenous catheter presenting with fever and fatigue with signs and symptoms of catheter infection likely has catheter-associated infection.
Gram-positive organisms (e.g., staphylococcus aureus, streptococcus epidermidis) are responsible for most dialysis catheter-related infections. A positive culture of the same organism from two peripherally drawn blood samples confirms the diagnosis.
Empiric intravenous antibiotics should be given to all patients with suspected dialysis catheter-related infection, which can then be tailored according to the blood culture sensitivity results. Gram-positive coverage is achieved with vancomycin, and gram-negative coverage can be achieved with gentamicin or ceftazidime. Immediate removal of the catheter is also needed. A new catheter may be inserted once blood cultures become negative for organism growth.
All patients with staphylococcus aureus bacteremia should undergo an echocardiogram to evaluate for the presence of endocarditis. Pursuit of an echocardiogram is especially important in the setting of risk factors for infective endocarditis, such as patients on hemodialysis.