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Difficulty: MediumPreoperative and Postoperative Care

A 72-year-old man is evaluated on postoperative day 4 following an elective right hemicolectomy for colon cancer. He has a history of chronic obstructive pulmonary disease (COPD). Yesterday, he developed a fever of 38.6°C (101.5°F). At that time, blood, urine, and sputum cultures were obtained, and empiric intravenous piperacillin-tazobactam was initiated. Today, his temperature is 38.2°C (100.8°F), blood pressure is 120/78 mmHg, and heart rate is 88/min. Lung auscultation reveals mild expiratory wheezing consistent with his baseline COPD, but no crackles or signs of respiratory distress. His surgical incision is clean, dry, and intact with no erythema. The indwelling urinary catheter, placed just before surgery, is still present. Urine culture results have just returned, showing greater than 10510^5 CFU/mL of Escherichia coli. The isolate is susceptible to ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole, but resistant to ampicillin. Blood and sputum cultures show no growth so far. Which of the following are appropriate next steps in the management of this patient? (Select all that apply.)

  1. Remove the indwelling urinary catheterAnswer
  2. Change the antibiotic regimen to intravenous ceftriaxoneAnswer
  3. C
    Continue intravenous piperacillin-tazobactam for broad-spectrum coverage
  4. D
    Obtain a computed tomography scan of the abdomen and pelvis
  5. E
    Administer intravenous furosemide for suspected acute decompensated heart failure

Answer

The appropriate next steps are to remove the indwelling urinary catheter and change the antibiotic regimen to intravenous ceftriaxone.
The correct answers involve removing the indwelling urinary catheter and changing the antibiotic regimen to intravenous ceftriaxone. This patient has a confirmed catheter-associated urinary tract infection (CAUTI), a common cause of fever on postoperative days 3 to 5. The management of CAUTI requires a two-pronged approach: source control and targeted antimicrobial therapy. Removing the urinary catheter is critical to eliminate the biofilm and nidus of infection. Additionally, the culture results indicate that the Escherichia coli is susceptible to ceftriaxone. In accordance with the principles of antibiotic stewardship, empiric broad-spectrum antibiotics (such as piperacillin-tazobactam) must be de-escalated to a targeted, narrower-spectrum agent (ceftriaxone) as soon as specific sensitivities are known.

Step-by-Step Solution

1
Identify the definitive source of the postoperative fever.
The positive urine culture (greater than 10510^5 CFU/mL of E. coli) confirms a catheter-associated urinary tract infection (CAUTI) as the cause of the fever on postoperative day 4.
Fever in the postoperative period requires systematic evaluation, and microbiological data establishes the diagnosis.
2
Determine the appropriate physical intervention for CAUTI.
Remove the indwelling urinary catheter.
The catheter serves as a nidus for infection due to biofilm formation. Source control through removal or exchange is essential for clearing the infection.
3
Adjust antimicrobial therapy based on culture and sensitivity data.
De-escalate the antibiotic from piperacillin-tazobactam to ceftriaxone.
Principles of antibiotic stewardship require narrowing the spectrum of coverage once specific organism sensitivities are known to prevent resistance and complications.

Key Concept

Management of catheter-associated urinary tract infections requires both source control (catheter removal) and antibiotic stewardship (de-escalation to targeted therapy).
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Topics

Preoperative and Postoperative Care

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