Category Archives: Guidelines

Clinical Pearls: PD-related peritonitis

One of the most common complications of peritoneal dialysis is peritonitis. Things to remember:

  • Diagnosis: Peritoneal fluid with >100 nucleated cells (usually >50% PMNs)
  • Pathophysiology: Skin-related (usually gram positive) vs. Secondary (enteric, usually gram-negative and polymicrobial)
  • Empiric treatment: Should cover gram positive and negative organisms. A frequently used combination is a first-generation cephalosporin (i.e. cefazolin) plus an anti-pseudomonal cephalosporin (i.e. cefepime). If the patient or population has a high frequency of methicillin-resistant organisms, vancomycin is a reasonable choice for gram-positive coverage.
  • Drug delivery: Intra-peritoneal (IP) preferred to intravenous (IV) route due to increased local concentration with IP. Vancomycin, aminoglycosides and cephalosporins can be mixed with dialysate solution and achieve therapeutic blood levels (must monitor closely)
  • Indications for catheter removal:

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Information based on ISPD 2005 guidelines for PD-related peritonitis

New & Improved! CDC STD Guidelines 2015

The CDC released their Mortality & Morbidity Weekly Report on June 5, 2015 which is comprised of the latest STD prevention, diagnosis, and treatment guidelines.These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection.

Continue reading New & Improved! CDC STD Guidelines 2015

A Practical Guide to the Novel Anticoagulants

This morning, Dr. Craig Malloy, Richard A. Lange, M.D. Chair in Cardiology, gave an amazing update for internists on New Therapies fo Atrial Fibrillation. One of the most important topics covered was the noval anticoagulants, or NOACS. Here is a quick review for use in the clinic or hospital!

Dabigatran, rivaroxaban and apixaban are three new drugs that have different mechanisms of action, daily doses, and metabolic and elimination profiles.

Dabigatran (Pradaxa) is a direct thrombin inhibitor (it inhibits factor II) that has a half-life of about 12-14 hours and needs to be administered twice daily. It partially binds plasma proteins and can therefore be partially dialysed. Pradaxa is only eliminated renally: it is therefore contraindicated in patients whose creatinine clearance is

Rivaroxaban (Xarelto) is a direct factor X inhibitor with a half-life of 5-13 hours, but completely binds plasma proteins. It is administered once daily with evening meal in NVAF patients, and twice daily in those with DVT or PE. It is eliminated by the kidney and liver, and can be used at a lower dose if creatinine clearance is15 mL/min in NVAF patients; its use should be avoided in DVT/PE patients whose creatinine clearance is

Apixaban (Eliquis) is a direct factor X inhibitor with a half-life of 9-14 hours, but completely binds plasma proteins. It is administered twice daily and eliminated by kidney and liver. It should not be used if creatinine clearance is

NOAC trial comparisons

Turiel M, Galaverna S, Colombo C, Gianturco L, Stella D (2015) Practical Guide to the New Oral Anticoagulants. J Gen Pract 3:194. doi: 10.4172/2329-9126.1000I194

HIT(T): Duration of Anticoagulation

  • Bilateral lower extremity compression ultrasonography may be considered in patients with HIT, whether or not there is clinical evidence of lower-limb DVT, because silent DVT is common and its presence may influence the recommended duration of anticoagulation.
  • For patients with HIT-associated thrombosis (i.e. HITT), anticoagulate for a defined course (typically 3 months) as with other provoked thromboses.
  • For patients with HIT without thrombosis (i.e. isolated HIT), the optimal duration of anticoagulation is unknown. Because there is an elevated risk of thrombosis extending 2 to 4 weeks after heparin is stopped, anticoagulation for up to 4 weeks should be considered.
  • For all patients, anticoagulation management should be based on an individualized risk/benefit assessment.

Grand Rounds Review: Delirium

This morning, Dr. Sharon Inouye gave us an excellent overview of delirium, with a focus on acute delirium in the elderly. She is the director of the Aging Brain Institute and Professor of Medicine at the Harvard School of Medicine and Beth Isreal Deaconess Medical Center. As a leading expert in the field, Dr. Inouye developed the Confusion Assessment Method (CAM), an internationally recognized method for identifying delirium. Here is a synopsis of her talk, with salient points that directly apply to our clinical practice.

Risk Factors for Delirium

  • Underlying dementia
  • Older age
  • Co-morbid illness
  • Severity of medical illness
  • Infection
  • ‘High-risk’ medication use (see below!)
  • Diminished activities of daily living
  • Immobility
  • Sensory impairment (vision, hearing)
  • Urinary catheterization
  • Urea and electrolyte imbalance
  • Malnutrition

Potentially Inappropriate Medications for the Elderly

In 2012, the American College of Geriatrics released the Beers criteria for medications with potential harm (including risk for delirium) in the elderly – mant of the medications we most commonly use populate this list!

  • Anticholinergics
    • 1st generation antihistamines (diphenhydramine, chlorpheniramine, etc.)
    • Anti-parkinson agents (benztropine)
    • Anti-spasmodics (dicyclomine, hyoscyamine, etc.)
  • Anti-microbials (Nitrofurantoin – pulm toxicity)
  • CNS medications
    • Tricyclics (amitriptyline, imipramine, doxepin – very antichol)
    • Conventional and Atypical Anti-psychotics
    • Benzos (increased risk of cognitive impairment)
  • Sedative/Hypnotics (zolpidem, eszopiclone, etc.)
  • Anti-arrhythmics (disopyramide, etc.)
  • Antitussives (dextromethorphan, etc.)
  • Anti-vertigo meds (meclizine, etc.)
  • H2-blockers (famotidine, etc.)
  • Mydriatics (atropine, etc.)

The list goes on, for more information, click here.

Diagnosis/Identification of Delirium

The Confusion Assesment Method


(to use the CAM, click the image above to visit the HELP website)


  • Non-pharmacologic measures are best! Guidelines do not recommend pharmacologic management as a first line, except for a few specific situations.
    • Re-orientation
    • Reduce medications
    • Reduce length of stay
    • Maintain day-night cycle
    • Familar surroundings and people
    • Remove catheters!
    • Maintain nutritional balance
  • Drug treatment may reduce agitation, but may prolong delirium duration and cognitive decline.
    • Pearl – reserve for patients with severe agitation which will:
      1. Cause interruption of essential medical therapy (i.e. intubation)
      2. Pose potential harm to the patient or staff
    • Recommended Approach: 
      • Haloperidol 0.25-0.50 mg PO or IM (avoid IV – short acting and can precipitate torsades de pointes)
      • Repeat dose q30 minutes until patient is manageable (maximum dose 3-5mg/24 hours)
      • Maintenance: 50% of loading dose divided over the next 24 hours
      • Taper dose of the next several days