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Difficulty: HardPreoperative and Postoperative Care

A 68-year-old man is evaluated on postoperative day 5 following an elective right hemicolectomy for colon adenocarcinoma. Over the past 12 hours, he has developed a new-onset fever, generalized malaise, and worsening abdominal pain. His medical history is significant for heart failure with preserved ejection fraction and diet-controlled type 2 diabetes mellitus. His temperature is 39.1°C (102.4°F), blood pressure is 128/76 mmHg, pulse is 114/min, and respiratory rate is 22/min. Oxygen saturation is 95% on room air. Physical examination reveals a mildly distended abdomen with focal tenderness in the right lower quadrant, but no involuntary guarding or rebound. The surgical incision is clean, dry, and intact. Auscultation of the lungs reveals fine crackles at the bases bilaterally, which are unchanged from his preoperative assessment. Blood cultures that were drawn 24 hours ago during a transient low-grade temperature elevation are now returning positive for *Escherichia coli* that is susceptible to ceftriaxone. Which of the following are the most appropriate next steps in management? (Select 2)

  1. Computed tomography of the abdomen and pelvis with contrastAnswer
  2. Intravenous ceftriaxone therapyAnswer
  3. C
    Intravenous piperacillin-tazobactam and vancomycin therapy
  4. D
    Incentive spirometry and chest physiotherapy
  5. E
    Intravenous furosemide therapy

Answer

The most appropriate next steps are computed tomography of the abdomen and pelvis with contrast to identify the source of the infection, and initiation of intravenous ceftriaxone therapy based on the known susceptibilities.
The correct next steps reflect a dual approach to a late postoperative complication: anatomical diagnosis and targeted medical therapy. Fever on postoperative day 5 following a bowel resection strongly suggests an intra-abdominal source such as an anastomotic leak or abscess. A computed tomography (CT) scan of the abdomen and pelvis with contrast is the gold standard imaging modality to identify these complications and can guide percutaneous drainage if an abscess is present. Furthermore, because the patient has documented *Escherichia coli* bacteremia with known susceptibilities, the most appropriate pharmacologic step is to initiate targeted, narrow-spectrum therapy with ceftriaxone. This treats the underlying systemic infection while adhering strictly to antimicrobial stewardship guidelines.

Step-by-Step Solution

1
Analyze the timing and clinical presentation of the postoperative fever.
The patient has a high fever and localized right lower quadrant abdominal pain on postoperative day 5 following a bowel resection.
Fever on postoperative days 5-7 following abdominal surgery is highly suspicious for a deep space surgical site infection, such as an anastomotic leak or intra-abdominal abscess.
2
Evaluate the laboratory data provided in the vignette.
Blood cultures are positive for E. coli that is susceptible to ceftriaxone.
This confirms a Gram-negative bacteremia, almost certainly originating from an enteric source in the abdomen, and provides direct guidance for antimicrobial therapy.
3
Determine the necessary diagnostic and therapeutic interventions.
Order a CT scan of the abdomen and pelvis, and begin targeted ceftriaxone therapy.
The CT scan is necessary to confirm the presence of an abscess or leak and to evaluate for potential percutaneous drainage. Targeted antibiotic therapy with ceftriaxone is required to treat the bacteremia while adhering to antibiotic stewardship principles.

Key Concept

Management of Postoperative Fever and Antimicrobial Stewardship
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Topics

Preoperative and Postoperative Care

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