From the Guidelines
Management of postoperative fever of 101°F (38.3°C) should begin with a thorough assessment to identify the underlying cause while providing symptomatic relief, and the most recent evidence suggests that fever during the first 48 hours usually arises from noninfectious or unknown causes 1. Initial management includes acetaminophen 650mg orally every 6 hours or ibuprofen 400mg every 6 hours as needed for fever and discomfort. Ensure adequate hydration with oral fluids or IV fluids if the patient cannot drink. A systematic evaluation should follow the "5 Ws" approach:
- Wind (atelectasis, pneumonia)
- Water (urinary tract infection)
- Wound (surgical site infection)
- Walking (deep vein thrombosis)
- Wonder drugs (medication reactions). Physical examination should focus on the respiratory system, surgical site, urinary tract, and legs. Basic investigations include complete blood count, urinalysis, chest X-ray, and wound assessment. Specific cultures (blood, urine, wound) should be obtained before starting antibiotics if infection is suspected. Early mobilization, incentive spirometry every hour while awake, and pulmonary toilet are important preventive measures. Postoperative fever is common within the first 48 hours due to the inflammatory response to surgical trauma and typically resolves without specific treatment, as stated in the guidelines for evaluation of new fever in critically ill adult patients 1. However, fever beyond 48 hours or accompanied by concerning symptoms requires more aggressive evaluation and management of the underlying cause. If the patient has <5 cm of erythema and induration, and if the patient has minimal systemic signs of infection (temperature <38.5°C, WBC count <12 000 cells/µL, and pulse <100 beats/minute), antibiotics are unnecessary, according to the practice guidelines for the diagnosis and management of skin and soft tissue infections 1. Patients with temperature >38.5°C or heart rate >110 beats/minute or erythema extending beyond the wound margins for >5 cm may require a short course (eg, 24–48 hours) of antibiotics, as well as opening of the suture line. The antibiotic choice is usually empiric but can be supported by Gram stain, culture of the wound contents, and the site of surgery. For example, an SSI following an operation on the intestinal tract or female genitalia has a high probability of a mixed gram-positive and gram-negative flora with both facultative and anaerobic organisms, and antibiotics considered suitable for treatment of intra-abdominal infection are appropriate 1.
From the Research
Postoperative Fever Management
- Postoperative fever of 101 degrees Fahrenheit should be evaluated with a focused approach, considering the patient's history, targeted physical examination, and further studies if appropriate 2
- Most fevers that develop within the first 48 hours after surgery are benign and self-limiting, but it is critical to recognize the minority of fevers that demand immediate attention 2
- A helpful mnemonic for evaluating postoperative fever is the "four Ws": wind (pulmonary causes), water (urinary tract infection), wound (surgical site infection), and "what did we do?" (iatrogenic causes) 2
Antibiotic Therapy
- Broad-spectrum antimicrobials such as cefepime, piperacillin-tazobactam, and meropenem are often used to treat postoperative infections, but their use should be guided by antibiotic guidelines and formal infectious disease consultation 3
- Monotherapy with meropenem has been shown to be as effective as combination therapy with ceftazidime and amikacin for empirical treatment of febrile neutropenic patients 4
- Adding vancomycin to perioperative prophylaxis has been shown to decrease deep sternal wound infections in high-risk cardiac surgery patients 5
Treatment Considerations
- Single-dose cefotaxime has been shown to be as effective and less costly than multiple-dose cefotaxime for common surgical procedures lasting less than 3 hours 6
- The choice of antibiotic therapy should be based on the suspected or confirmed cause of the infection, as well as the patient's individual risk factors and medical history 2, 3, 6, 4, 5