What is the best course of action for a post-operative hysterectomy patient with fever, normal chest x-ray, and unremarkable wound healing 5 days after surgery?

Post-Hysterectomy Day 5 Fever Workup

For a patient 5 days post-hysterectomy with isolated fever of 38.8°C and otherwise unremarkable findings, you should proceed with urine analysis and culture (Option B), followed by blood cultures if systemic signs develop, as fever at this timepoint has shifted from benign inflammatory response to high probability of infection. 1, 2

Why Day 5 Fever Demands Investigation

• Fever occurring on postoperative day 5 represents a critical temporal shift where infection becomes equally or more likely than benign causes, as the systemic inflammatory response from surgery typically resolves within 48-72 hours 1, 2
• By postoperative day 4-5, fever is no longer attributable to normal surgical stress and warrants targeted infectious workup 1, 2
• The 96-hour mark (day 4) is the inflection point where fever probability shifts significantly toward infectious rather than inflammatory causes 1

Recommended Diagnostic Approach

First-Line Investigation: Urinalysis and Culture (Option B)

Urinary tract infection is the most appropriate initial target for several reasons:

• Duration of catheterization is the single most important risk factor for UTI development 1, 2
• Pelvic surgery, particularly hysterectomy, increases UTI risk due to anatomical proximity and instrumentation 3
• Urinalysis and culture provide high diagnostic yield with minimal invasiveness 1
• UTI is one of the three most common causes of infectious morbidity after hysterectomy (along with vaginal cuff infection and wound infection) 4

Second Priority: Blood Cultures (Part of Option A)

Blood cultures should be obtained when temperature ≥38°C is accompanied by systemic signs of infection:

• The yield of blood cultures increases significantly with signs of bacteremia or sepsis beyond isolated fever 1, 2
• For isolated fever at 38.8°C without hemodynamic instability or altered mental status, blood cultures can be deferred initially but obtained if fever persists or worsens 1
• Obtain blood cultures before starting any empiric antibiotics to avoid compromising diagnostic accuracy 1

CBC Consideration (Part of Option A)

• CBC with differential can assess for leukocytosis but is less specific than cultures 5
• While helpful for trending, CBC alone does not identify the infectious source 1

Medication Review (Option C)

Medication review is important but secondary to infectious workup:

• Drug fever is a diagnosis of exclusion and less likely on day 5 unless new medications were recently introduced 2
• This should not delay obtaining appropriate cultures 1

Critical Wound Assessment

Despite "unremarkable wound healing" noted, daily wound inspection remains mandatory:

• Look specifically for purulent drainage, spreading erythema >5 cm from incision, induration, warmth, tenderness, or swelling 1, 2
• Vaginal cuff infection is a common cause of post-hysterectomy fever and may not be visible on external examination 4
• If any purulent drainage is present, obtain Gram stain and culture before starting antibiotics 1, 2
• Surgical site infections account for approximately 25% of costs associated with surgical procedures 1, 2

Common Pitfalls to Avoid

• Assuming atelectasis without investigation - atelectasis should be a diagnosis of exclusion and does not typically cause fever 1, 6
• Delaying investigation because chest X-ray and wound appear normal - isolated fever on day 5 still warrants targeted evaluation 1
• Starting empiric antibiotics before obtaining cultures - this compromises diagnostic accuracy 1
• Overlooking urinary source - particularly relevant given catheterization during surgery 1, 2

When to Escalate

Immediate escalation is required if the patient develops:

• Hemodynamic instability (hypotension, tachycardia) 1
• Signs of severe infection or sepsis 1
• Respiratory compromise 1
• Altered mental status 1
• Persistent fever beyond 48-72 hours despite appropriate therapy, which may indicate inadequate source control, resistant organisms, or need for advanced imaging 1, 2

Advanced Imaging Considerations

For patients with recent pelvic surgery and unexplained fever:

• The Society of Critical Care Medicine and Infectious Diseases Society of America recommend performing CT (in collaboration with surgical service) if etiology is not readily identified by initial workup 7
• CT imaging can identify pelvic abscess, hematoma, or septic pelvic thrombophlebitis (rare but important consideration in post-hysterectomy patients with persistent fever unresponsive to antibiotics) 8

Algorithmic Summary

1. Obtain urinalysis and urine culture immediately 1, 2
2. Perform thorough wound and vaginal cuff examination 1, 2
3. Obtain blood cultures if systemic signs present or fever persists 1, 2
4. Review medications for drug fever (diagnosis of exclusion) 2
5. If initial workup negative and fever persists >48 hours, obtain CT pelvis in consultation with surgery 7
6. Consider septic pelvic thrombophlebitis if fever unresponsive to broad-spectrum antibiotics 8