Postoperative Day 5 Fever After Hysterectomy
The most appropriate next step is urinalysis and urine culture (Option B), as this patient is on postoperative day 5 with fever and likely had an indwelling catheter for ≥72 hours during the perioperative period. 1
Rationale for Urinalysis and Culture
Fever on postoperative day 5 shifts the probability significantly toward infectious causes rather than benign inflammatory response, as the systemic inflammatory response from surgery typically resolves within 48-72 hours. 1
After 96 hours (day 4-5), fever is equally likely to represent infection as other causes, making investigation mandatory rather than observation. 1, 2
Duration of catheterization is the single most important risk factor for UTI development, and urinalysis with culture should be performed in any postoperative patient who had an indwelling catheter for ≥72 hours and develops fever, even without urinary symptoms. 1
The patient is asymptomatic, which is typical—catheter-associated UTIs frequently present with fever alone without dysuria, urgency, or other localizing symptoms. 1
Why Not the Other Options?
CBC and Blood Cultures (Option A)
- Blood cultures are indicated when temperature ≥38°C is accompanied by systemic signs of infection beyond isolated fever, such as hemodynamic instability, altered mental status, or signs of bacteremia/sepsis. 1, 3
- In this stable, asymptomatic patient with isolated fever, blood cultures are premature and should be obtained only if urinalysis is positive or other sources are identified. 1
Chest X-ray (Option C)
- A chest radiograph is not required within the first 72 hours (or beyond) when fever is the sole finding; obtain chest X-ray only if respiratory signs or symptoms develop. 1, 2
- Assuming atelectasis as the cause without investigation is a common pitfall—atelectasis should be a diagnosis of exclusion. 1
Review Medication (Option D)
- While drug fever is a consideration, it should not be the first step when more common infectious causes (particularly catheter-associated UTI) have not been ruled out on postoperative day 5. 1
Wound Assessment Remains Essential
- Daily wound inspection is mandatory even though the wound appears clean, specifically looking for purulent drainage, spreading erythema (>5 cm), induration, warmth, tenderness, or swelling. 1
- Surgical site infections account for approximately 25% of costs associated with surgical procedures and most frequently manifest between postoperative days 4-6. 1
- However, do not culture a clean-appearing wound without signs of infection—this wastes resources and may lead to treatment of colonization rather than infection. 1, 2
Critical Pitfalls to Avoid
- Starting empiric antibiotics before obtaining appropriate cultures compromises diagnostic accuracy and should be avoided. 1
- Delaying investigation because other findings are unremarkable is inappropriate—isolated fever on day 5 warrants targeted evaluation. 1
- Assuming benign postoperative fever is dangerous at this timepoint, as the normal inflammatory response should have resolved by 48-72 hours. 2
When to Escalate
- Immediate escalation is required if the patient develops hemodynamic instability, signs of severe infection, respiratory compromise, or altered mental status. 1
- Persistent fever beyond 48-72 hours despite appropriate therapy may indicate inadequate source control, resistant organisms, or non-infectious causes requiring imaging studies. 1