In a 45-year-old woman on postoperative day 5 after hysterectomy who has fever with a clean wound and no other symptoms, what is the most appropriate next investigation?

Postoperative Day 5 Fever Management

In a 45-year-old woman on postoperative day 5 after hysterectomy with isolated fever and a clean wound, the most appropriate next step is urinalysis and culture (Answer B), as fever at this timepoint shifts probability significantly toward infectious causes, with urinary tract infection being the most common source in gynecologic surgery patients with indwelling catheters. 1

Rationale for Urinalysis and Culture

• Timing is critical: Fever occurring on postoperative day 5 (beyond 96 hours) is equally likely to represent infection as other causes, unlike early postoperative fever within 48-72 hours which is typically benign inflammatory response 1, 2

• Urinary tract infections are the leading concern in post-hysterectomy patients, particularly when:

  • An indwelling bladder catheter has been in place for >72 hours (duration of catheterization is the single most important risk factor for UTI development) 1, 2
  • The patient is asymptomatic otherwise (UTI can present with fever alone in postoperative patients) 1

• Guidelines specifically address this scenario: Urinalysis and culture should be performed for febrile patients having indwelling bladder catheters for ≥72 hours, even without urinary symptoms 3

Why Not the Other Options?

CBC and Blood Cultures (Option A)

• Blood cultures are reserved for patients with temperature ≥38°C accompanied by systemic signs of infection beyond isolated fever (hemodynamic instability, altered mental status, signs of bacteremia/sepsis) 1, 4
• Not the first-line investigation for isolated fever without systemic signs 1

Chest X-ray (Option C)

• Not mandatory during the initial 72 hours postoperatively if fever is the only indication 3
• Only indicated if respiratory symptoms develop 2, 4
• Atelectasis should be a diagnosis of exclusion, not a first assumption 1, 2

Review Medication (Option D)

• While drug fever is a consideration, it should not delay appropriate infectious workup 1
• This is a diagnosis of exclusion after ruling out infectious causes 1

Essential Concurrent Actions

Daily wound inspection is mandatory even though the wound appears clean:

• Look specifically for purulent drainage, spreading erythema (>5 cm from incision), induration, warmth, tenderness, swelling, or any necrosis 1, 2
• Surgical site infections account for approximately 25% of costs associated with surgical procedures and commonly manifest between postoperative days 4-6 3, 2
• Do not culture the wound if there are no symptoms or signs suggesting infection 3, 2

Common Pitfalls to Avoid

• Assuming atelectasis without investigation: This is a diagnosis of exclusion and should not delay appropriate workup 1, 2
• Delaying investigation because other findings are unremarkable: Isolated fever on day 5 warrants targeted evaluation 1
• Starting empiric antibiotics before obtaining appropriate cultures: This compromises diagnostic accuracy 1
• Treating asymptomatic bacteriuria: If urine culture is positive but the patient remains asymptomatic, treatment may not be indicated 5, 6

When to Escalate

Immediate escalation is required if the patient develops:

• Hemodynamic instability 1, 4
• Signs of severe infection or sepsis 1, 4
• Respiratory compromise 1
• Altered mental status 1, 4
• Persistent fever beyond 48-72 hours despite appropriate therapy (may indicate inadequate source control, resistant organisms, or non-infectious causes requiring imaging studies) 1