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Difficulty: MediumPreoperative and Postoperative Care

A 72-year-old man is evaluated for a new-onset fever on postoperative day 4 following an open repair of a ventral hernia. He has been recovering well, tolerating a regular diet, and ambulating with assistance in the surgical ward hallways. An indwelling urethral catheter was placed prior to surgery and removed on postoperative day 2. Today, his temperature is 38.6∘C38.6^\circ\text{C} (101.5∘F101.5^\circ\text{F}). Blood pressure is 128/76 mm Hg128/76\text{ mm Hg}, pulse is 96/min96/\text{min}, and respirations are 16/min16/\text{min}. Oxygen saturation is 96%96\% on room air. The patient reports feeling slightly fatigued but denies shortness of breath, cough, nausea, or calf pain. He notes that he has been urinating more frequently than usual since the catheter was removed, which he attributes to his postoperative intravenous fluids. Examination shows a soft abdomen with mild tenderness near the surgical incision. The incision is clean and intact with no erythema, induration, or purulent discharge. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in management?

  1. Obtain a urinalysis and urine cultureAnswer
  2. B
    Request a portable chest radiograph
  3. C
    Obtain a CT scan of the abdomen and pelvis
  4. D
    Perform a lower extremity venous Doppler ultrasound
  5. E
    Administer empiric broad-spectrum antimicrobial therapy

Answer

Obtain a urinalysis and urine culture
The most appropriate next step is to obtain a urinalysis and urine culture. This patient presents with a new-onset fever on postoperative day 4, accompanied by urinary frequency shortly after the removal of an indwelling urethral catheter. This clinical picture is highly indicative of a catheter-associated urinary tract infection (CAUTI). Based on the classic '5 Ws' mnemonic for postoperative fever, 'Water' refers to urinary tract infections, which most commonly occur on postoperative days 3 to 5. The correct approach is to confirm the diagnosis with a urinalysis and identify the specific organism via culture to guide targeted antibiotic therapy.

Step-by-Step Solution

1
Analyze the timing of the patient's postoperative fever.
The fever is occurring on postoperative day 4.
The timing of a postoperative fever is a critical diagnostic clue, commonly remembered via the '5 Ws' mnemonic.
2
Evaluate the patient's symptoms and clinical risk factors associated with this specific timeframe.
The patient had an indwelling catheter removed two days ago and now reports urinary frequency.
Fever on postoperative days 3 to 5 is most frequently associated with urinary tract infections ('Water'), particularly in patients with a history of urinary catheterization.
3
Determine the most appropriate initial diagnostic step based on the suspected etiology.
A urinalysis and urine culture should be obtained.
Confirming the presence of a urinary tract infection and identifying the causative organism is necessary to guide appropriate, targeted antimicrobial therapy.

Key Concept

The timing of postoperative fever provides crucial clues to its etiology (the '5 Ws'). Fever presenting on postoperative days 3 to 5 is most commonly due to a urinary tract infection ('Water'), especially following the use of an indwelling urethral catheter.
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Topics

Preoperative and Postoperative Care

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