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Difficulty: MediumPreoperative and Postoperative Care

A 61-year-old woman is seen on the surgical ward due to a new-onset fever. She is currently on postoperative day 4 following an elective open total abdominal hysterectomy and bilateral salpingo-oophorectomy for complex atypical endometrial hyperplasia. The nursing staff notes that her temperature spiked to 38.8°C (101.8°F) two hours ago. The patient reports experiencing generalized fatigue, urinary urgency, and mild suprapubic discomfort, but she denies having a cough, dyspnea, or calf pain. Her indwelling urinary catheter, placed during the surgery, was removed 48 hours ago. Her temperature is 38.8°C (101.8°F), blood pressure is 126/82 mm Hg, pulse is 98/min, and respirations are 16/min. Pulse oximetry is 98% on room air. Physical examination reveals clear lung fields bilaterally. The abdomen is soft, with mild tenderness noted in the suprapubic region but no rebound or guarding. The surgical midline incision is well-approximated with intact staples; there is a 2-mm margin of light erythema along the wound edges, but no fluctuance, induration, or purulent exudate is present. Bilateral lower extremities show no edema or tenderness. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Duplex ultrasonography of the lower extremities
  3. C
    Intravenous piperacillin-tazobactam and vancomycin therapy
  4. D
    Bedside exploration of the surgical wound
  5. Urinalysis and urine cultureAnswer

Answer

Urinalysis and urine culture
Urinalysis and urine culture is the most appropriate next step for a stable patient presenting with a fever, urinary urgency, and suprapubic discomfort on postoperative day 4. This presentation is classic for a catheter-associated urinary tract infection, which typically manifests between postoperative days 3 and 5 (the 'Water' in the 5 Ws of postoperative fever). Diagnosis must be confirmed with laboratory testing before beginning targeted antibiotics.

Step-by-Step Solution

1
Determine the postoperative day and identify the patient's new symptoms.
The patient is on postoperative day 4 and presents with a new-onset fever, urinary urgency, and suprapubic discomfort.
Establishing the timeline of a postoperative fever is critical for forming a differential diagnosis based on the classic '5 Ws'.
2
Correlate the symptom timeline with the most likely etiology of the fever.
Fever on postoperative days 3 to 5 (the 'Water' phase), combined with urinary symptoms and recent indwelling catheter use, strongly points to a urinary tract infection.
Catheter-associated urinary tract infections are a leading cause of fever during this specific postoperative window.
3
Select the most appropriate diagnostic test to confirm the suspected etiology.
A urinalysis and urine culture should be ordered to definitively diagnose a urinary tract infection before initiating antibiotics.
Diagnostic confirmation is required to practice appropriate antimicrobial stewardship and ensure targeted therapy.

Key Concept

Postoperative fever occurring on days 3 to 5 is most commonly caused by a urinary tract infection, particularly in patients who had an indwelling catheter; the most appropriate next step is to obtain a urinalysis and urine culture.
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Topics

Preoperative and Postoperative Care

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