Pocket ObGyn – Postoperative Fever
See Abbreviations

Hx: Review records for preop infxn, intraop complications, xfusion, med list, allergies, urinary catheter, vascular access Ask about diarrhea, productive cough, skin rash, new onset pain, sputum, preop illness.
Physical exam: Temperature (& trends), pulse, bld pres, & respiratory Examine skin (rash), lungs (decreased breath sounds, rales, rhonchi), heart (new murmurs), abd (tenderness or peritoneal signs), operative site (including vaginal cuff, poss), catheter/drain/IV sites, & lower extremities (DVT).
Lab: Based on Hx, exam, & May include urinalysis & culture, CBC w/ diff, bld culture ´2 before Abx (1 set from indwelling central line if present), sputum culture (generally low yield), wound culture (low yield), CXR, lower limb US for DVT, & PE protocol CT scan. W/u for other medical conditions as appropriate.

Common causes of postoperative fever by onset/timing
Immediate (1st 24 h)	– Primarily noninfectious: Med effect, xfusion rxn, preop infxn, malig hyperthermia (rarely)
Acute (1–7 d)	– Infectious: Nosocomial infxn (most commonly PNA; in critical pts may be VAP, aspiration PNA) & UTI, Clostridium difficile; community-acquired infxns; SSI & vascular catheter–related infxns, endometritis. – Noninfectious: Surgical site inflammation—common after uterine Surg (eg, myomectomy); med rxn; thromboembolism (DVT, PE); CVA; pancreatitis; EtOH withdrawal; acute gout; fat embolism; hyperthyroidism
Subacute (1–4 w)	– Primarily infectious: SSI; central venous catheter–related; UTI; sinusitis (esp if NG tube in place); PNA; C. difficile; surgical site abscess. – Noninfectious: Med rxns; thromboembolism (DVT, PE). Consider septic pelvic thrombophlebitis
Delayed (>1 mo)	– Primarily infectious: Community-acquired or nosocomial infxns; SBE; C. difficile; FB infxn; osteomyelitis; unrelated infxns

Mgmt: Based on etiology, if Abx indicated, target to suspected sources; tailor to culture results when available

Surgical Site Infections (SSI)

SSI introduced at time of Surg by endogenous flora
Common organisms: Staphylococcus aureus, enterococcus, Escherichia coli, coagulase-negative staphylococci. Gyn SSI more likely caused by gram-negative bacilli, enterococci, group B streptococcus, anaerobes
Infxn rate by category of procedure: Clean 6%, clean-contaminated 3.6%, contaminated/dirty 10.5% (Arch Surg 1999;134:1041)
RFs: Obesity, existing infxn, diabetes, smoking, corticosteroids, immunosuppression, poor nutrition, long duration of Surg, active bact vaginosis or cervicitis

Prophylaxis (Infect Control Hosp Epidemiol 2008 29:S51)

Skin prep: Chlorhexidine-alcohol superior to povidone-iodine (NEJM 2010;362:18)
Sterile technique, avoid razor hair removal (trim/clip instead), avoid hyperglycemia
Antimicrobial ppx: (Am J Obstet Gynecol 2008;199:301.e1, Obstet Gynecol 2009;113:1180.) Administer <30 min before Surg (Ann Surg 2009;250:10), or at time of anesthesia Additional dose may be req for obese pts, Surg >4 h or EBL >1500 mL

Antibiotic prophylaxis for ob-gyn surgery
Procedure	Antibiotic options (single dose)
Hysterectomy & urogynecologic procedures	Cefazolin* 1 g IV (2 g IV if BMI >35, wt >100 kg or >220 lb) Clindamycin 600 mg IV + gentamicin 1.5 mg/kg IV or ciprofloxacin 400 mg IV or aztreonam 1 g IV Metronidazole 500 mg IV + gentamicin 1.5 mg/kg IV or ciprofloxacin 400 mg IV
Surgical abortion	Doxycycline 100 mg PO/IV 1 h before, 200 mg PO after Metronidazole 500 mg PO BID ´5 d
HSG with PID or hydrosalpinx	Doxycycline 100 mg PO BID ´5 d
Cesarean deliv	A 1st generation cephalosporin (eg, cefazolin 1 g IV) Clindamycin 600 mg IV + gentamicin 1.5 mg/kg IV
*No ppx for* laparoscopy, laparotomy, hysteroscopy, IUD placement, endometrial bx, or urodynamics.
Acceptable alternatives: Cefotetan, cefoxitin, cefuroxime, or ampicillin–sulbactam. From Obstet Gynecol* 2009;113:1180; and Obstet Gynecol 2011;117:1472.

Clinical Manifestations (Infect Control Hosp Epidemiol 1992; 13:606; Infect Dis Obstet Gynecol

2003;11:65)

Incision cellulitis: Warmth, swelling, erythema, pain w/o fluid collection
Superficial incisional SSI (skin, subcutaneous tissue): Positive cx, purulent drainage
Deep incisional SSI (fascia, muscle): Spont dehiscence, abscess
Vaginal cuff cellulitis: Edema, induration, & erythema of the vaginal cuff
Organ space: Pelvic abscess, vaginal cuff abscess
Nec fasciitis: Erythema, swelling/edema, pain disproportionate to exam (followed by analgesia), crepitus, gray-colored discharge

CBC (leukocytosis ± bandemia), gram stain + cx of incision or abscess fluid, bld culture
US: Inexpensive, sens 56–93%, spec 86–98% for pelvic abscess (J Emerg Med

2011;40:170)

(J Reprod Med 2005;50(3):203)

Incisional cellulitis: Antimicrobial rx w/ gram-positive coverage, consider MRSA coverage
For more complicated SSI: Parenteral antibiotic therapy ± abscess drainage
Nec fasciitis: Emergent wide local debridement + beta-lactam/beta-lactamase inhib
clindamycin (antitoxin effect) + MRSA coverage