Management of Postoperative Fever in Pediatric Patients

Initial Assessment

Fever occurring 20 days post-surgery is highly concerning for infection, as non-infectious postoperative fever typically resolves within 72 hours, according to the Infectious Diseases Society of America 1
Immediate wound inspection is essential to evaluate for surgical site infection (SSI), looking for purulent drainage, erythema, tenderness, or swelling, as recommended by the Infectious Diseases Society of America 3
Complete physical examination should focus on abdominal examination for tenderness, guarding, or distension suggesting intra-abdominal abscess or persistent infection, as well as respiratory assessment for signs of pneumonia and urinary symptoms suggesting urinary tract infection, according to the Society of Critical Care Medicine 1

Laboratory studies should include complete blood count with differential to assess for leukocytosis, C-reactive protein and/or erythrocyte sedimentation rate to evaluate inflammatory response, and blood cultures if sepsis is suspected, as recommended by the Infectious Diseases Society of America 1
Imaging studies, such as abdominal CT scan with intravenous contrast, are the preferred imaging modality to identify potential intra-abdominal abscesses or collections, according to the Society of Critical Care Medicine 1
Urinalysis and urine culture, especially if urinary catheterization was performed during hospitalization, should be performed to evaluate for urinary tract infection, as recommended by the Infectious Diseases Society of America 5

If intra-abdominal abscess is identified, source control with percutaneous drainage or surgical intervention is the primary management, and obtain cultures from any drainage to guide antimicrobial therapy, as recommended by the Infectious Diseases Society of America 4
Empiric antimicrobial therapy should be initiated while awaiting culture results, with appropriate regimens including an aminoglycoside-based regimen, a carbapenem, a β-lactam/β-lactamase inhibitor combination, or an advanced-generation cephalosporin plus metronidazole, according to the Infectious Diseases Society of America 4
For surgical site infections, open infected wounds to allow drainage, and if significant surrounding erythema or systemic signs of infection are present, antimicrobial therapy is indicated, as recommended by the Infectious Diseases Society of America 3

Daily assessment of fever curve, pain control, and clinical status should be performed, and repeat imaging if clinical improvement is not observed within 48-72 hours of appropriate therapy, as recommended by the Infectious Diseases Society of America 4
Adjust antimicrobial therapy based on culture and susceptibility results, and continue antimicrobial therapy until the patient is afebrile, has normal white blood cell count, and shows clinical improvement, according to the Infectious Diseases Society of America 4, 6

Delaying imaging studies in a child with persistent postoperative fever beyond 96 hours, failing to consider deep surgical site infections or organ space infections when superficial wound appears normal, and inadequate source control are common pitfalls to avoid, as warned by the Society of Critical Care Medicine 1 and the Infectious Diseases Society of America 3, 4
Overuse of broad-spectrum antibiotics when targeted therapy based on cultures would be more appropriate is also a common pitfall to avoid, according to the Infectious Diseases Society of America 4, 6