What is the most appropriate step in managing a postoperative patient with intermittent fever, normal abdomen and chest, normal initial investigations, and a clean wound?

Management of Postoperative Fever with Normal Examination Findings

Reassurance is the most appropriate step for a postoperative patient with 1-week intermittent fever, normal abdominal and chest examination, normal investigations, and a clean wound.

Understanding Postoperative Fever Timing and Significance

Postoperative fever evaluation should follow a systematic approach based on timing and clinical presentation:

Early vs. Late Postoperative Fever

• Fever within 48-72 hours after surgery is usually non-infectious and self-limiting 1
• Fever beyond 96 hours (4 days) postoperatively is more likely to represent infection 1
• In this case, the patient has a 1-week intermittent fever, which falls into the later category

Assessment of Current Clinical Status

• The patient has:
  • Normal abdominal examination
  • Normal chest examination
  • Normal investigations
  • Clean surgical wound

Decision Algorithm for Postoperative Fever at 1 Week

Step 1: Evaluate the Wound

• A clean wound without signs of infection (erythema, purulence, tenderness, swelling) makes surgical site infection unlikely 1
• Surgical wounds should be examined daily, but not cultured if there are no signs of infection 1

Step 2: Consider Common Infectious Sources

• The "four Ws" approach helps evaluate postoperative fever 2:
  • Wind (pulmonary): Normal chest exam rules out pneumonia
  • Water (urinary): Normal investigations likely included urinalysis
  • Wound: Clean wound without signs of infection
  • "What did we do?" (iatrogenic): Consider drug fever

Step 3: Consider Non-Infectious Causes

• Drug fever is a common non-infectious cause of postoperative fever
• Antibiotics, particularly penicillins and cephalosporins, can cause drug fever 7-10 days after initiation 2, 3
• Drug fever typically presents with normal physical examination and laboratory findings

Rationale for Reassurance

The patient's presentation strongly suggests drug fever because:

1. Timing is consistent (1 week postoperatively)
2. Physical examination is normal
3. Laboratory investigations are normal
4. Wound is clean without signs of infection

Studies have shown that extensive fever evaluations in postoperative patients with otherwise normal findings have low diagnostic yield 4. In one prospective study, only 18% of febrile postoperative patients were diagnosed with an infection, and in half of those cases, the diagnosis was made by physical examination alone without additional testing 4.

Important Caveats

• If fever persists or new symptoms develop, reassessment is necessary
• Maintain high suspicion for deep venous thrombosis and pulmonary embolism in postoperative patients, especially those with risk factors 1
• Drug fever typically resolves within 72 hours of discontinuing the offending medication
• Document the suspected medication allergy in the patient's chart to avoid future exposure

When to Consider Further Investigation

Further investigation would be warranted if:

• Temperature exceeds 38.5°C or heart rate exceeds 110 beats/minute 1
• Erythema extends beyond wound margins for >5 cm 1
• New symptoms develop (e.g., respiratory symptoms, urinary symptoms)
• Patient develops signs of systemic toxicity

In the absence of these findings, reassurance is the most appropriate step, with close follow-up to ensure resolution of fever.