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Difficulty: MediumPreoperative and Postoperative Care

During morning rounds, a 65-year-old woman is evaluated on postoperative day 4 following an elective right hemicolectomy for a large adenomatous polyp. Her medical history includes heart failure with preserved ejection fraction, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). An indwelling urinary catheter, placed prior to surgery, remains in situ to monitor urine output. Today, she reports feeling feverish and having mild chills but denies cough, shortness of breath, dysuria, or calf pain. Her temperature is 38.6°C (101.5°F), blood pressure is 132/80 mmHg, pulse is 104/min, and respirations are 16/min. Pulse oximetry is 96% on room air. Cardiopulmonary examination reveals distant breath sounds and scattered end-expiratory wheezes that are unchanged from her preoperative baseline. There is no jugular venous distention or peripheral edema. The abdomen is soft and mildly tender near the surgical site. The midline abdominal incision is clean, dry, and intact without surrounding erythema or drainage. Which of the following is the most appropriate next step in management?

  1. A
    Obtain a chest radiograph and initiate empiric levofloxacin therapy
  2. B
    Administer intravenous furosemide and obtain a serum brain natriuretic peptide level
  3. Remove the urinary catheter and obtain a voided urine sample for cultureAnswer
  4. D
    Initiate empiric intravenous piperacillin-tazobactam and vancomycin therapy
  5. E
    Open the surgical incision and obtain deep tissue cultures

Answer

Remove the urinary catheter and obtain a voided urine sample for culture
The correct answer is to remove the urinary catheter and obtain a voided urine sample for culture. This patient is experiencing a new-onset fever on postoperative day 4. In the postoperative period, the timing of a fever provides critical clues to its etiology, often summarized by the '5 Ws': Wind (lungs, POD 1-2), Water (urinary tract, POD 3-5), Walking (venous thromboembolism, POD 4-6), Wound (surgical site, POD 5-7), and Wonder drugs (drug fever, POD 7+). A fever on POD 4 in a patient with an indwelling urinary catheter is highly suspicious for a catheter-associated urinary tract infection (CAUTI). The most appropriate initial management for suspected CAUTI is the removal of the unnecessary catheter (to eliminate the nidus of infection) and obtaining a voided midstream or clean-catch urine sample for culture before initiating targeted antibiotic therapy.

Step-by-Step Solution

1
Analyze the timing of the patient's postoperative fever.
The fever has developed on postoperative day 4.
Timing is the most critical factor in determining the likely etiology of a postoperative fever.
2
Correlate the timing with potential sources of infection (the '5 Ws').
Postoperative day 4 corresponds to 'Water', pointing to a urinary tract infection as the most likely source.
Catheter-associated urinary tract infections classically present between postoperative days 3 and 5.
3
Evaluate the physical examination findings to rule out other potential causes.
The lung exam is at baseline (ruling out pneumonia or acute heart failure exacerbation), and the incision is clean (ruling out a surgical site infection).
Confirming the absence of other focal findings strengthens the suspicion of a urinary source.
4
Determine the most appropriate management for the suspected diagnosis.
The Foley catheter should be removed and a urine culture obtained before giving any antibiotics.
Removing the nidus of infection and obtaining accurate source cultures are the foundational steps of managing a catheter-associated infection.

Key Concept

The evaluation of postoperative fever relies heavily on the timing of symptom onset (the '5 Ws'); a fever on postoperative days 3-5 in a patient with an indwelling Foley catheter should prompt immediate catheter removal and a urinalysis with culture to evaluate for a catheter-associated urinary tract infection.
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Topics

Preoperative and Postoperative Care

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