What is the most appropriate initial step in managing a post-hysterectomy patient with fever (hyperthermia) 5 days after surgery?

Management of Post-Hysterectomy Fever on Day 5

The most appropriate initial step is comprehensive wound inspection combined with obtaining blood cultures and urinalysis with culture (options A and B), as fever on postoperative day 5 is highly concerning for infection and requires immediate diagnostic workup. 1, 2

Why Day 5 Fever Demands Action

Fever occurring 5 days post-hysterectomy falls outside the benign inflammatory window and represents a critical threshold:

• Fever after 96 hours (day 4) is equally likely to be caused by surgical site infection or another infectious source, making this a high-risk scenario that cannot be dismissed as normal postoperative inflammation 1, 2
• Non-infectious postoperative fever typically resolves within 72 hours, so persistence to day 5 strongly suggests an infectious etiology 1, 2
• Surgical site infections rarely occur in the first 48 hours but become increasingly likely after day 3-4 2, 3

Immediate Diagnostic Workup Required

Priority 1: Wound Examination (Part of Physical Assessment)

• Remove all surgical dressings and inspect the incision thoroughly for purulent drainage, spreading erythema (measure extent), induration, warmth, tenderness, swelling, or any necrosis 2, 3
• If erythema extends >5 cm from incision with induration or any necrosis is present, immediate intervention with wound opening, empiric antibiotics, and dressing changes is required 2, 3
• Obtain Gram stain and culture of any purulent drainage before starting antibiotics 2, 3

Priority 2: Laboratory Studies (Option A - CBC and Cultures)

• Obtain complete blood count with differential to assess for leukocytosis and inflammatory response 1
• Blood cultures are mandatory when temperature ≥38.8°C, as this represents systemic signs of infection requiring identification of bacteremia 1, 2, 3
• C-reactive protein and/or erythrocyte sedimentation rate to evaluate inflammatory response 1

Priority 3: Urinalysis and Culture (Option B)

• Urinalysis and urine culture are essential, especially given the likelihood of urinary catheterization during hysterectomy 1, 2
• Duration of catheterization is the most important risk factor for urinary tract infections 2, 3
• Urinary tract infection is one of the most common causes of postoperative fever after gynecologic surgery 1, 2

Chest X-Ray Consideration (Option C)

• Chest X-ray is NOT mandatory on day 5 if fever is the only indication and there are no respiratory symptoms 2, 3
• However, CXR becomes indicated if respiratory symptoms develop (cough, dyspnea, hypoxia) 2
• Given the clinical scenario describes "unremarkable chest x-ray," this has already been performed and is not the priority action 2

Medication Review (Option D)

• While medication review is part of comprehensive care, it is not the primary diagnostic step for fever on day 5 post-hysterectomy 1, 2
• Drug fever is a diagnosis of exclusion after infectious causes are ruled out 2

Empiric Antibiotic Selection

If wound infection is identified or suspected, start empiric antibiotics immediately:

• For hysterectomy (GI tract/female genital tract operation): Cephalosporin + metronidazole, levofloxacin + metronidazole, or carbapenem to cover both aerobic and anaerobic bacteria 2, 3
• Adjust therapy based on culture and susceptibility results 1, 2

Critical Pitfalls to Avoid

• Delaying diagnostic workup beyond 96 hours postoperatively when fever persists 1, 2
• Failing to consider deep surgical site infections or organ space infections when superficial wound appears normal - if wound examination is unremarkable but fever persists, consider imaging (abdominal CT with IV contrast) to identify intra-abdominal abscesses 1
• Assuming all early postoperative fever is benign - this assumption is only valid within the first 72 hours 1, 2, 4
• Inadequate source control - antibiotics alone are insufficient if abscess or infected collection requires drainage 1

Answer to the Question

Options A (CBC and cultures) and B (Urinalysis and culture) are both correct and should be performed together as the initial diagnostic workup. Blood cultures are particularly critical given the temperature of 38.8°C, which indicates systemic infection requiring identification of the causative organism 1, 2, 3. Option C (CXR) is not indicated unless respiratory symptoms develop, and Option D (medication review) is not the priority diagnostic step 2, 3.