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Difficulty: MediumPreoperative and Postoperative Care

On the fourth day following an elective left total hip arthroplasty, a 68-year-old female develops a new fever. Her maximum temperature over the past shift was 38.6°C (101.5°F). She has a past medical history of hypertension and chronic obstructive pulmonary disease. The patient complains of increased urinary frequency, burning with urination, and vague suprapubic discomfort. An indwelling urethral catheter was utilized intraoperatively and discontinued 24 hours prior to this current evaluation. Her chronic mild cough remains at baseline with clear sputum. Physical examination demonstrates distant breath sounds bilaterally without focal crackles or wheezing. The surgical wound is well-approximated without erythema, fluctuance, or purulent drainage. Examination of the lower extremities reveals bilateral trace pitting edema without calf tenderness or asymmetric swelling. Vital signs include a blood pressure of 134/82 mmHg, pulse of 94/min, and respiratory rate of 16/min. Oxygen saturation is 95% on ambient air. Which of the following is the most appropriate next step in management?

  1. Obtain a urinalysis and urine cultureAnswer
  2. B
    Request a chest radiograph and reinforce incentive spirometry
  3. C
    Begin empiric therapy with intravenous piperacillin-tazobactam
  4. D
    Perform a lower extremity venous duplex ultrasound
  5. E
    Give an intravenous dose of furosemide and restrict fluid intake

Answer

The most appropriate next step is to obtain a urinalysis and urine culture to evaluate for a catheter-associated urinary tract infection.
The correct answer identifies the need to evaluate the urinary tract. This patient is presenting with a fever on postoperative day 4 following Foley catheter removal, accompanied by classic cystitis symptoms (dysuria, frequency, suprapubic discomfort). This clinical picture is highly characteristic of a catheter-associated urinary tract infection (CAUTI). In a hemodynamically stable patient, the most appropriate next step is to perform diagnostic testing with a urinalysis and urine culture to confirm the presence of infection and guide targeted antimicrobial therapy.

Step-by-Step Solution

1
Analyze the timing of the fever in the postoperative course.
The fever occurs on postoperative day 4.
The timeline helps narrow the differential diagnosis based on the '5 Ws' (Wind, Water, Walking, Wound, Wonder drugs). Day 3-5 fevers are classically associated with urinary tract sources ('Water').
2
Correlate the timeline with the patient's specific symptoms and recent history.
The patient has dysuria, increased urinary frequency, and suprapubic pain following the recent removal of a Foley catheter.
These localized findings strongly point to a urinary tract infection rather than pulmonary, wound, or deep venous etiologies.
3
Determine the appropriate initial diagnostic or therapeutic intervention.
A urinalysis and urine culture must be obtained.
Before initiating antimicrobial therapy for a suspected CAUTI in a stable patient, appropriate laboratory confirmation and pathogen isolation are required to practice good antibiotic stewardship.

Key Concept

Postoperative fevers occurring on days 3 to 5 are most commonly caused by urinary tract infections, particularly in patients who had an indwelling urinary catheter. The diagnosis should be confirmed with a urinalysis and urine culture prior to antibiotic therapy.
Estimated Time:1m 15s
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Topics

Preoperative and Postoperative Care

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