A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 48-year-old female with a history of hypertension, type II diabetes mellitus, hypothyroidism, and asthma undergoes a scheduled total abdominal hysterectomy for symptomatic fibroids. She is given a dose of preoperative prophylactic antibiotics. Her urinary catheter is removed on post-operative day one. She is on low-molecular-weight heparin for deep vein thrombosis prophylaxis. On post-operative day four, the patient complains of abdominal pain. She denies cough, nausea, vomiting, or dysuria, but has had 3-4 loose stools over her hospitalization. Her temperature is 101.0°F (38.3°C), blood pressure is 97/59 mmHg, pulse is 106/min, and respirations are 16/min. The surgical wound has new erythema with dusky patches and abundant cloudy discharge. The patient reports new decreased sensation around her wound site. Her lungs are clear to auscultation and abdomen is soft with hypoactive bowel sounds. She has no costovertebral angle tenderness. Urinalysis is within normal limits and urine culture grows >100,000 CFU/mL of Escherichia coli.
Which of the following is the best next step in management?
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A
Discontinue low-molecular-weight heparinIncorrect. Stopping LMWH does not address the infection that is driving this patient's fever and hypotension; DVT prophylaxis is unrelated to the wound process.
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B
Oral levofloxacin for 3 daysIncorrect. Oral levofloxacin for 3 days is appropriate for uncomplicated cystitis, but this patient has no urinary symptoms and a wound emergency requiring surgery — not oral antibiotics.
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C
Vancomycin/piperacillin-tazobactam/clindamycin and observationIncorrect. Broad-spectrum antibiotics alone (without debridement) are insufficient for necrotizing fasciitis; antibiotics do not reach necrotic tissue effectively, and delay increases mortality.
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D
Vancomycin/piperacillin-tazobactam/clindamycin and debridement of the surgical woundCorrect. Necrotizing fasciitis requires both broad-spectrum antibiotics with toxin coverage (vanc/pip-tazo/clinda) AND urgent surgical debridement.
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E
Vancomycin monotherapy and wound packingIncorrect. Vancomycin alone misses gram-negative and anaerobic organisms typical of polymicrobial necrotizing fasciitis, and simple packing without debridement leaves necrotic tissue in place — both inadequate for this surgical emergency.
↑ Tap an answer to reveal the reasoning
Answer: D. On postoperative day 4 this patient has fever, hypotension, tachycardia, and a wound with dusky erythema, cloudy discharge, and loss of sensation around the wound. The combination of rapidly evolving wound changes, anesthesia at the site, and systemic signs of sepsis defines necrotizing soft tissue infection (necrotizing fasciitis). The E. coli on urine culture in a recently catheterized patient without urinary symptoms or pyuria is asymptomatic bacteriuria and is a distractor.
Necrotizing fasciitis is a surgical emergency. Empiric therapy must cover MRSA, gram-negatives (including Pseudomonas), anaerobes, and toxin production — vancomycin plus piperacillin-tazobactam plus clindamycin (clindamycin halts streptococcal/staphylococcal toxin production via 50S inhibition). Antibiotics alone are insufficient — the infection progresses along fascial planes faster than antibiotics can penetrate the devitalized tissue. Urgent surgical debridement of necrotic tissue is the definitive intervention; mortality rises sharply with delay.
Clues that distinguish necrotizing from simple cellulitis include pain out of proportion, anesthesia from nerve necrosis, dusky/violaceous skin, crepitus, and systemic toxicity.
**Why each option:**
**A.** Stopping LMWH does not address the infection that is driving this patient's fever and hypotension; DVT prophylaxis is unrelated to the wound process.
**B.** Oral levofloxacin for 3 days is appropriate for uncomplicated cystitis, but this patient has no urinary symptoms and a wound emergency requiring surgery — not oral antibiotics.
**C.** Broad-spectrum antibiotics alone (without debridement) are insufficient for necrotizing fasciitis; antibiotics do not reach necrotic tissue effectively, and delay increases mortality.
**D.** Correct. Necrotizing fasciitis requires both broad-spectrum antibiotics with toxin coverage (vanc/pip-tazo/clinda) AND urgent surgical debridement.