A 52-year-old man undergoes elective open cholecystectomy for chronic cholecystitis. On postoperative day 5, the patient develops fever (38.5°C), increasing abdominal pain, and serosanguinous drainage from the lower end of the surgical wound. The wound edges are erythematous and edematous. On examination, there is fluctuance at the wound site. What is the most appropriate next step in management?

Explanation

## Clinical Scenario Analysis The patient presents with classic signs of **surgical site infection (SSI) with abscess formation** on postoperative day 5: - Fever and systemic signs - Serosanguinous drainage (indicates infection, not simple seroma) - Fluctuance (loculated collection) - Erythema and edema of wound edges ## Management Principle **Key Point:** A fluctuant wound collection with fever and purulent/serosanguinous drainage requires **urgent surgical drainage**, not observation or imaging delays. **High-Yield:** The presence of fluctuance is a clinical diagnosis of abscess — it mandates drainage. Waiting for imaging or antibiotics alone risks systemic sepsis and delayed source control. ## Why Wound Exploration & Drainage is Correct 1. **Source control is paramount** — antibiotics alone cannot penetrate a loculated collection effectively 2. **Fluid culture guides definitive therapy** — empiric broad-spectrum coverage is started, but culture directs de-escalation 3. **Prevents progression** — early drainage reduces risk of sepsis, necrotizing fasciitis, and prolonged morbidity 4. **Timing** — postoperative day 5 is ideal; waiting risks systemic deterioration ## Surgical Site Infection Management Algorithm ```mermaid flowchart TD A[Postop fever + wound signs]:::outcome --> B{Fluctuance present?}:::decision B -->|Yes| C[Urgent wound exploration & drainage]:::action B -->|No| D{Signs of cellulitis only?}:::decision D -->|Yes| E[IV antibiotics + close monitoring]:::action D -->|No| F[Imaging: ultrasound or CT]:::action C --> G[Send fluid for C&S]:::action C --> H[Start empiric broad-spectrum ABx]:::action G --> I[De-escalate based on culture]:::action E --> J{Improvement in 48 hrs?}:::decision J -->|No| K[Reconsider imaging & drainage]:::action ``` **Clinical Pearl:** In the early postoperative period (days 3–7), SSI with fluctuance is almost always bacterial. Gram-positive organisms (Staph aureus, Streptococcus) and gram-negatives (E. coli, Klebsiella) are common; empiric coverage should include both until culture results guide therapy.