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Difficulty: MediumPreoperative and Postoperative Care

A 7272-year-old man is evaluated on the surgical ward for a new-onset fever. He is currently on postoperative day 33 following an elective open lower anterior resection for rectal adenocarcinoma. His medical history is significant for hypertension and type 22 diabetes mellitus. His temperature is 38.8∘C38.8^\circ\text{C} (101.8∘F101.8^\circ\text{F}), blood pressure is 132/82 mm Hg132/82\text{ mm Hg}, pulse is 94/min94/\text{min}, and respirations are 16/min16/\text{min}. Oxygen saturation is 97%97\% on room air. The patient reports mild, well-controlled pain at his surgical site but notes a new onset of burning with urination and a sensation of incomplete bladder emptying. His indwelling urinary catheter was removed 2424 hours ago. Physical examination shows a soft, non-distended abdomen with normal active bowel sounds. The surgical incision is clean, dry, and intact without erythema, induration, or purulent drainage. Lung fields are clear to auscultation bilaterally. The calves are soft and non-tender. Which of the following is the most appropriate next step in management?

  1. Obtain a urinalysis and urine cultureAnswer
  2. B
    Order a portable chest radiograph
  3. C
    Initiate empiric intravenous piperacillin-tazobactam
  4. D
    Perform lower extremity venous duplex ultrasonography
  5. E
    Obtain a computed tomography scan of the abdomen and pelvis

Answer

Obtain a urinalysis and urine culture
This patient is on postoperative day 33 and presenting with a new fever, dysuria, and a sensation of incomplete voiding shortly after the removal of an indwelling urinary catheter. This clinical picture is highly suspicious for a catheter-associated urinary tract infection (CAUTI). The '5 Ws' of postoperative fever classically describe the timeline of common complications: Wind (atelectasis/pneumonia, days 11-22), Water (UTI, days 33-55), Walking (DVT/PE, days 55-77), Wound (surgical site infection, days 77-99), and Wonder drugs (drug fever, anytime). Given the characteristic timeline and localizing urinary symptoms, the most appropriate next step in management is to establish a definitive diagnosis by obtaining a urinalysis and urine culture before initiating targeted antibiotic therapy.

Step-by-Step Solution

1
Analyze the timeline of the postoperative fever.
The patient is on postoperative day 3, which classically corresponds to urinary tract etiologies.
The '5 Ws' (Wind, Water, Walking, Wound, Wonder drugs) provide a heuristic for diagnosing postoperative fever, with 'Water' (UTI) peaking around days 3 to 5.
2
Evaluate the clinical signs and symptoms.
The patient has dysuria, a sensation of incomplete emptying, and a recent history of urinary catheterization, with no respiratory, abdominal, or extremity abnormalities.
Focal symptoms help narrow the differential diagnosis. The recent catheter removal heavily predisposes the patient to a catheter-associated urinary tract infection (CAUTI).
3
Determine the most appropriate diagnostic intervention.
A urinalysis and urine culture are required to confirm the diagnosis.
Before initiating targeted antimicrobial therapy, the presence of infection must be documented and the causative organism identified to ensure proper antibiotic stewardship.

Key Concept

Evaluation of postoperative fever using the '5 Ws' timeline, specifically recognizing catheter-associated urinary tract infections ('Water') on postoperative day 3-5.
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Topics

Preoperative and Postoperative Care

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