What is the appropriate management for an adult woman on postoperative day 20 after a left mastectomy who remains inpatient with a fever of 39.9 °C and left chest‑wall pain, without cough, sputum production, or dysuria?

Management of Postoperative Day 20 Fever After Mastectomy

On postoperative day 20 with a fever of 39.9°C and chest wall pain, immediately remove the surgical dressing and thoroughly inspect the mastectomy wound for signs of surgical site infection, then obtain blood cultures before starting empiric antibiotics if systemic signs are present. 1, 2

Immediate Wound Assessment

Direct visualization of the surgical site is the highest-yield first step at this timepoint. 1, 3

• Inspect specifically for purulent drainage (any amount is diagnostic of infection), spreading erythema >5 cm from the incision, induration, warmth, tenderness, swelling, or tissue necrosis 1, 2
• If erythema extends >5 cm with induration or any necrosis is present, this requires immediate intervention with wound opening, empiric antibiotics, and dressing changes 2, 3
• Obtain Gram stain and culture of any purulent drainage before starting antibiotics 1, 2

Diagnostic Workup Priority

At postoperative day 20, fever is highly likely to represent infection rather than benign inflammatory response, as surgical inflammation typically resolves within 48-72 hours. 1, 3

Blood Cultures

• Obtain blood cultures immediately when temperature ≥38°C (this patient has 39.9°C) is accompanied by systemic signs beyond isolated fever 1, 2
• The combination of high fever (39.9°C) and chest wall pain constitutes systemic signs warranting blood cultures 4, 1

Imaging Studies

• Perform chest radiograph to evaluate for pneumonia or other pulmonary complications, as this is recommended for febrile ICU/hospitalized patients 4
• Strongly consider CT imaging of the chest/operative area in collaboration with the surgical service, as this patient remains hospitalized on day 20 with unexplained fever—this extended timeframe and lack of resolution suggests a deeper or occult source 4, 1

Urinary Evaluation

• If the patient has had or currently has an indwelling catheter for ≥72 hours, obtain urinalysis and urine culture even without dysuria, as catheter duration is the single most important risk factor for UTI 1, 2
• Given the absence of dysuria and no mention of catheterization, urinary source is less likely but should not be completely excluded 1

Empiric Antibiotic Selection

If wound infection is identified or systemic signs of sepsis are present, start empiric antibiotics immediately after obtaining cultures. 2, 3

• For clean wounds of trunk (mastectomy site): start cefazolin or vancomycin if MRSA risk is high (consider vancomycin given prolonged hospitalization of 20 days) 2, 3
• Adjust antibiotics based on culture results and clinical response 2, 3

Critical Red Flags Requiring Escalation

Immediate escalation is mandatory if any of the following develop: 1, 2

• Hemodynamic instability (hypotension, tachycardia beyond baseline)
• Altered mental status
• Respiratory compromise
• Signs of necrotizing infection (severe pain out of proportion, skin discoloration, crepitus)
• Persistent fever beyond 48-72 hours despite appropriate antibiotics (may indicate inadequate source control, resistant organisms, or abscess requiring drainage) 1, 2

Common Pitfalls to Avoid

• Do not assume atelectasis without investigation—atelectasis should be a diagnosis of exclusion and does not explain day 20 fever 1
• Do not delay investigation because other findings seem unremarkable—isolated fever at this timepoint warrants aggressive evaluation 1
• Do not start empiric antibiotics before obtaining appropriate cultures unless the patient is hemodynamically unstable 1, 2
• Do not overlook drug-induced fever in a patient hospitalized for 20 days on multiple medications, though infection must be ruled out first 5

Additional Considerations

• Maintain high suspicion for deep venous thrombosis or pulmonary embolism given prolonged hospitalization, sedentary status, and potential malignancy (mastectomy indication) 1, 3
• Consider 18F-FDG PET/CT if initial workup fails to establish an etiology and the patient remains febrile, as this has 85-100% sensitivity for occult infection sources 4
• If the patient had abdominal or pelvic surgery in addition to mastectomy, CT of those regions should be performed in collaboration with surgery 4