What are the next steps for a patient 7 days post-cholecystectomy, currently on oxycodone (oxycodone) 5mg every 4 hours as needed and tylenol (acetaminophen) 1000mg, presenting with persistent pain and purulent drainage at the incision site?

Immediate Management of Post-Cholecystectomy Wound Infection with Persistent Pain

This patient requires urgent evaluation for surgical site infection and possible bile duct injury—do not manage this in primary care alone; arrange immediate surgical consultation while initiating diagnostic workup and antibiotic therapy. 1, 2

Critical Red Flags Present

This patient has two alarm symptoms that mandate prompt investigation:

• Purulent drainage from incision indicates surgical site infection requiring source control 2
• Persistent pain at 7 days post-op suggests possible complications including bile duct injury, biloma, or abscess formation 1, 2

Immediate Actions in Primary Care

Laboratory Workup

• Obtain liver function tests immediately: direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin to differentiate between bile leakage versus bile duct obstruction 1, 2
• Inflammatory markers: CBC, CRP, procalcitonin, and lactate to evaluate severity of infection and sepsis 1, 2

Imaging Studies

• Order triphasic abdominal CT scan as first-line imaging to detect intra-abdominal fluid collections, biloma, or abscess 1, 2
• Consider contrast-enhanced MRCP if CT shows ductal dilation or fluid collections to precisely localize any bile duct injury 1, 2

Antibiotic Initiation

• Start broad-spectrum antibiotics immediately if signs of infection are present (purulent drainage qualifies) 1, 2
• Recommended agents: piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem 1
• Timing is critical: initiate within 1 hour if patient shows signs of severe sepsis or shock; within 4-6 hours for moderate infection 3

Wound Management

• Examine the incision site for extent of purulent drainage, erythema, induration, and fluctuance 2
• If abscess or fluid collection is present at the incision, this requires drainage—either by opening the wound or image-guided drainage 1, 2

Pain Management Adjustment

The current oxycodone regimen may be inadequate:

• Continue oxycodone 5mg every 4 hours as needed but consider increasing to 10mg if pain remains uncontrolled 4, 5
• Continue acetaminophen 1000mg (ensure not exceeding 4g/24 hours) as it provides effective analgesia post-cholecystectomy 6, 7
• Pain reduction of 1-2 cm on visual analog scale is typical with adequate analgesia 7

Surgical Consultation

Contact the operating surgeon immediately for:

• Evaluation of possible bile duct injury (bile leak presents with persistent pain, fever, and can have purulent-appearing fluid that may actually be infected bile) 1, 2
• Determination if ERCP with biliary sphincterotomy and stent placement is needed for bile leak 2
• Assessment for need of percutaneous drainage of any collections 1, 2

Antibiotic Duration

Once source control is achieved:

• For surgical site infection with abscess: 5-7 days after drainage 1, 3
• If bile leak with infected collection (biloma): 5-7 days after percutaneous or surgical drainage 1, 3
• If Enterococcus or Streptococcus isolated: extend to 2 weeks to prevent infectious endocarditis 1, 3

Common Pitfalls to Avoid

• Do not assume purulent drainage is simply a superficial wound infection—it may represent infected bile or biloma requiring imaging and source control 1, 2
• Do not delay imaging beyond 24 hours in a patient with persistent pain and signs of infection 1, 2
• Do not continue antibiotics indefinitely without addressing anatomical problems such as bile leak or undrained collections 3
• Do not manage this patient entirely in primary care—surgical consultation is mandatory given the combination of persistent pain and purulent drainage at 7 days post-op 1, 2