The most appropriate next step in management is to begin broad-spectrum antibiotic coverage, such as vancomycin plus ceftazidime. This patient with end-stage kidney disease (ESKD) who is receiving dialysis via a catheter is at high risk for catheter-related bacteremia. Infection is the second most common cause of death in patients with ESKD (after cardiovascular disease), and catheter-related infections are an important cause of morbidity and mortality. It is therefore important to provide immediate empiric broad-spectrum antibiotics in patients dialyzing via a catheter who exhibit evidence of infection unless there is another obvious source of fever. Most dialysis-related bacteremias are caused by gram-positive bacteria, and empiric coverage must include therapy that takes into account the local resistance patterns of Staphylococcus aureus. Additionally, gram-negative organisms should also be covered until culture results are known and appropriate, focused antimicrobial therapy is prescribed.

If blood cultures remain negative, empiric antibiotics may be stopped if symptoms have resolved and no other potential source of infection has been identified. If blood cultures return positive, it is usually advisable to remove the catheter because success rates for catheter salvage are low for most organisms. If there is no evidence of infection of the catheter tunnel, dialysis catheters can be safely exchanged over a wire in patients who have been asymptomatic on appropriate antibiotic therapy for at least 48 hours. However, either removing or exchanging the dialysis catheter in the setting of possible infection without antibiotic therapy is not appropriate.