What to do for a patient 8 days post-cesarean section (C-section) with pain at the surgical site, presence of sutures, and a low-grade fever?

Management of Post-Cesarean Section Surgical Site Infection

This patient requires immediate wound inspection with suture removal and incision opening, plus initiation of empiric antibiotics covering both aerobic and anaerobic organisms given the combination of pain, fever, and presence of sutures 8 days post-cesarean section. 1

Immediate Actions Required

Wound Management

• Remove sutures and open the incision to allow drainage - this is the primary intervention for surgical site infections 1
• Perform thorough wound inspection looking for purulent drainage, spreading erythema, induration, warmth, tenderness, or swelling 2
• Obtain Gram stain and culture of any purulent drainage before starting antibiotics 1
• Implement dressing changes 1

Assessment of Severity

The decision to add antibiotics depends on systemic signs 1:

Start antibiotics if ANY of the following are present:

• Temperature ≥38.5°C (101.3°F) 1
• Heart rate ≥110 beats/minute 1
• Erythema and induration extending >5 cm from wound edge 1
• White blood cell count >12,000/µL 1

If temperature <38.5°C without tachycardia: Observation with dressing changes and suture removal may suffice 1

Antibiotic Selection

For Cesarean Section Infections

C-sections involve nonsterile tissue (vaginal/GI tract proximity), requiring coverage for mixed aerobic-anaerobic bacteria 1:

Recommended regimens:

• Cephalosporin + metronidazole (e.g., ceftriaxone 1g IV every 24h + metronidazole 500mg IV every 8h) 1
• Fluoroquinolone + metronidazole (e.g., levofloxacin 750mg IV every 24h + metronidazole 500mg IV every 8h) 1
• Single-agent option: Piperacillin-tazobactam 3.375g IV every 6h or 4.5g every 8h 1
• Carbapenem (ertapenem 1g IV every 24h, meropenem 1g IV every 8h, or imipenem-cilastatin 500mg IV every 6h) 1

MRSA Coverage Consideration

• Add vancomycin 15mg/kg IV every 12h if patient has risk factors: nasal MRSA colonization, prior MRSA infection, recent hospitalization, or recent antibiotic use 1

Clinical Context: Timing Matters

At 8 days post-op, this fever is highly likely to be infectious 2:

• Fever in first 48 hours is typically benign inflammatory response 2, 3
• After 96 hours (day 4), surgical site infection becomes equally likely as other causes 2
• By day 8, infection is the primary concern 2, 4

Critical Pitfalls to Avoid

Do not delay surgical intervention waiting for culture results - source control (opening the wound) is the primary treatment 1

Do not assume superficial appearance means no deep infection - C-section infections can rapidly progress to involve fascia, fat, or muscle 1

Watch for signs of necrotizing infection requiring emergency surgical consultation: severe pain out of proportion to exam, skin necrosis, crepitus, hemodynamic instability, or rapid progression 1

Monitoring Plan

• Reassess wound daily for improvement 2
• Monitor temperature curve and vital signs 2
• Adjust antibiotics based on culture results when available 1
• If no improvement within 48-72 hours, consider imaging (CT) to evaluate for deeper abscess or collection 4