During morning rounds on his sixth postoperative day, a 60-year-old male patient is noted … — USMLE Step 2 CK

During morning rounds on his sixth postoperative day, a $60$ -year-old male patient is noted to have a new-onset fever. Six days ago, he underwent an open sigmoid colectomy to treat complicated diverticulitis. His medical history is significant for obesity, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. His temperature is $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), blood pressure is $132/84\text{ mm Hg}$ , pulse is $102/\text{min}$ , and respirations are $18/\text{min}$ . Oxygen saturation is $94\%$ on room air. He reports generalized fatigue and worsening pain around his abdominal incision. Physical examination reveals mild bilateral basilar crackles that clear with coughing. The abdomen is non-distended. The midline laparotomy incision exhibits a $5\text{-cm}$ area of erythema, induration, and tenderness. Gentle pressure applied adjacent to the incision yields thick, purulent fluid from between two surgical staples. There is no calf tenderness or swelling. Which of the following is the most appropriate next step in management?

A
Initiate empiric intravenous piperacillin-tazobactam and vancomycin
B
Obtain a superficial swab of the purulent exudate for culture
Remove the surgical staples to open and drain the woundAnswer
D
Obtain a CT scan of the abdomen and pelvis with intravenous contrast
E
Administer intravenous furosemide and perform a chest radiograph

Answer

The most appropriate next step is to remove the surgical staples to open and drain the wound.

This patient has developed a superficial surgical site infection (SSI), as evidenced by his new-onset fever, incisional erythema, induration, and purulent drainage on postoperative day 6. The classic timeline for postoperative fever follows the '5 Ws' mnemonic (Wind, Water, Walking, Wound, Wonder drugs), where wound infections typically manifest between days 5 and 7. The single most important initial step in managing a superficial SSI with purulence is achieving source control. This requires removing the surgical staples or sutures, opening the wound to allow complete drainage of the pus, and subsequently packing it to heal by secondary intention. While systemic antibiotics might be considered later if there is extensive surrounding cellulitis or signs of systemic sepsis, they are entirely secondary to mechanical drainage. Without opening the wound, the infection will not resolve.

Step-by-Step Solution

Analyze the patient's presentation and postoperative timeline.

The patient is on postoperative day 6 and presents with fever, marked incisional pain, erythema, and purulent drainage.

Identifying the timeline helps narrow the differential diagnosis for postoperative fever, often recalled using the '5 Ws' mnemonic.

Determine the most likely diagnosis based on the physical findings.

The presence of purulent drainage from the incision strongly indicates a superficial surgical site infection (SSI).

Purulence is the classic hallmark of a wound infection, which typically manifests between postoperative days 5 and 7 ('Wound').

Select the most appropriate initial management for this specific diagnosis.

The primary treatment for a purulent superficial SSI is mechanical drainage, achieved by removing the staples to open the wound.

Source control is the definitive management for superficial abscesses and wound infections; antibiotics cannot effectively clear an undrained collection.

Key Concept

Superficial surgical site infections typically present on postoperative days 5 to 7 and require immediate source control via opening and draining the wound.

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