What is the management of an infected surgical wound?

From the Guidelines

The primary and most important therapy for an infected surgical wound is to open the incision, evacuate the infected material, and continue dressing changes until the wound heals by secondary intention, as supported by the most recent and highest quality study 1.

Management Approach

When managing infected surgical wounds, a multifaceted approach is necessary. This includes:

• Assessing the wound for signs of infection such as erythema, purulence, increased pain, warmth, and systemic symptoms like fever.
• Opening, exploring, and debriding the wound to remove necrotic tissue, foreign material, and purulent discharge.
• Obtaining wound cultures before starting antibiotics to guide targeted therapy.

Antibiotic Therapy

Initial empiric antibiotic therapy may include coverage for Staphylococcus aureus and streptococci, but there is little to no evidence supporting the use of antibiotics in all cases of surgical site infections, especially when the wound can be adequately drained and managed with wound care alone 1.

• For mild to moderate infections, options such as cefazolin 1-2g IV every 8 hours or clindamycin 600-900mg IV every 8 hours may be considered.
• For severe or healthcare-associated infections, broader coverage with piperacillin-tazobactam 4.5g IV every 6-8 hours or vancomycin 15-20mg/kg IV every 8-12 hours may be necessary.

Wound Care

Wound care involves:

• Regular cleaning with normal saline or antiseptic solutions.
• Packing if needed.
• Appropriate dressing changes every 12-24 hours.

Additional Considerations

• Advanced wound therapies like negative pressure wound therapy may be beneficial for complex wounds.
• Nutritional support is essential as protein and calorie requirements increase during wound healing.
• Glycemic control should be maintained in diabetic patients, aiming for blood glucose levels below 180 mg/dL. This comprehensive approach addresses the infection while creating an optimal environment for wound healing, prioritizing morbidity, mortality, and quality of life as outcomes.

From the FDA Drug Label

SKIN AND SKIN STRUCTURE INFECTIONS Caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Viridans group streptococci, Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganii,1Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis1or Peptostreptococcus species SURGICAL PROPHYLAXIS The preoperative administration of a single 1 gram dose of Ceftriaxone for Injection may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated For surgical prophylactic use, to prevent postoperative infection in contaminated or potentially contaminated colorectal surgery, the recommended dosage schedule for adults is:a 15 mg/kg infused over 30 to 60 minutes and completed approximately one hour before surgery, followed by:b. 7. 5 mg/kg infused over 30 to 60 minutes at 6 and 12 hours after the initial dose

The management of an infected surgical wound may involve the use of antibiotics such as ceftriaxone or metronidazole.

• Ceftriaxone can be used to treat skin and skin structure infections caused by various bacteria, including Staphylococcus aureus and Escherichia coli 2.
• Metronidazole can be used for prophylaxis in contaminated or potentially contaminated colorectal surgery to prevent postoperative infection 3. It is essential to note that the choice of antibiotic and dosage regimen should be based on the specific type of infection, the causative organism, and the patient's individual needs.

From the Research

Management of Infected Surgical Wounds

• The management of acute wounds, including surgical site and post-traumatic infections, can be affected by malpractices leading to poor outcomes, prolonged hospital stays, and inappropriate use of antibiotic therapy 4.
• A multidisciplinary approach is needed to optimally manage patients with acute wound infections, and this includes avoiding certain malpractices such as prolonged surgical prophylaxis, underestimation of signs and symptoms, and omission of source control 4.

Antibiotic Prophylaxis

• The use of narrow-spectrum antibiotics, such as nafcillin, may offer an advantage in terms of prophylaxis for cardiac operations and hospital costs, as it reduces the incidence of staphylococcal infections without increasing resistance 5.
• Broad-spectrum antibiotics, such as ceftriaxone, may not provide additional benefits in terms of reducing infection rates, and may even contribute to the development of resistant superinfections 5.

Treatment of Complicated Skin and Soft Tissue Infections

• The Surgical Infection Society (SIS) guidelines recommend the use of adjuvant antimicrobial therapy after drainage of complex abscesses, and suggest alternative antimicrobial agents for the treatment of complicated skin and soft tissue infections 6.
• Linezolid, a synthetic oxazolidinone antibiotic, has been shown to be effective against Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecium (VRE) 7, 8.
• Combination therapy with linezolid and other antibiotics, such as ceftriaxone, may be a good approach to enhance efficacy and prevent the development of resistance in the treatment of complicated infections 7, 8.