What is the best course of action for an elderly woman, 2 weeks post-operative from Open Reduction Internal Fixation (ORIF) surgery, presenting with neutrophilia?

Management of Neutrophilia 2 Weeks Post-ORIF in an Elderly Woman

In an elderly woman 2 weeks post-ORIF with neutrophilia (80%), you should immediately evaluate for surgical site infection (SSI) and initiate empirical antibiotics if clinical signs of infection are present, as neutrophilia at this timepoint is a strong predictor of postoperative infection. 1, 2

Immediate Clinical Assessment

Evaluate for signs of surgical site infection:

• Examine the surgical site for fever, local swelling, redness, warmth, or purulent drainage 1
• Check vital signs for fever (≥38.0°C), tachycardia, or hypotension 3
• Assess for systemic inflammatory response syndrome (SIRS) criteria 1
• Note that 61.5% of patients with early periprosthetic joint infections have normal white blood cell counts, making neutrophil percentage particularly important 2

Diagnostic Workup

Obtain the following laboratory and imaging studies:

• Complete blood count with differential to calculate neutrophil-to-lymphocyte ratio (NLR) 2, 4
• Blood cultures (two sets from peripheral vein) before starting antibiotics 3
• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), though these remain elevated for weeks post-surgery and may not be specific 2
• Wound culture if any drainage is present 1
• Consider imaging of the surgical site if deep infection is suspected 3

Interpretation of Neutrophilia

The neutrophil percentage of 80% is clinically significant:

• NLR typically returns to preoperative levels within 2 weeks after surgery in uncomplicated cases 2
• Persistent or rising neutrophilia at 2 weeks post-ORIF strongly suggests infection 2, 4
• An NLR >2.77 at the suspected infection time has 84.6% sensitivity and 89.7% specificity for early periprosthetic joint infection 2
• Neutrophilia with lymphopenia (neutrophil-lymphocyte stress factor) correlates with severity of infection and systemic inflammation 5

Treatment Decision Algorithm

If clinical signs of infection are present (fever, wound changes, systemic symptoms):

• Start empirical IV antibiotics immediately within the first hour 3
• Use vancomycin PLUS either piperacillin-tazobactam or a carbapenem to cover MRSA, streptococci, and gram-negative organisms 1, 3
• This broad coverage is warranted given the elderly population, post-surgical state, and risk factors for SSI 1

If no clinical signs of infection but isolated neutrophilia:

• Monitor closely with daily assessment of vital signs and wound examination 3
• Repeat CBC with differential in 24-48 hours to assess trend 6
• Consider that neutrophilia may reflect ongoing physiologic stress response, though this should have resolved by 2 weeks 5, 2
• Maintain high index of suspicion as signs of infection may be minimal in elderly patients 3

Risk Factors to Consider

This elderly patient has multiple risk factors for SSI post-ORIF:

• Advanced age increases infection risk 1
• Diabetes mellitus (if present) significantly increases SSI risk 1
• ASA score ≥3, BMI, and comorbidities are additional risk factors 1
• The 2-week timepoint is within the typical window for early postoperative infections 2

Antibiotic Duration and Monitoring

If infection is confirmed:

• Continue antibiotics for minimum 5 days, extending if no clinical improvement 1
• Tailor antibiotics based on culture results when available 1
• Monitor daily until afebrile and clinical improvement is evident 3
• For deep bone/hardware infection, prolonged therapy (4-6 weeks) may be required 1

Critical Pitfall to Avoid

Do not rely solely on ESR and CRP at 2 weeks post-ORIF:

• These inflammatory markers remain persistently elevated for weeks after surgery even without infection 2
• ESR and CRP were not significantly different between infected and non-infected patients at 2 weeks post-surgery 2
• The neutrophil percentage and NLR are more specific markers at this timepoint 2, 4