What is the best course of treatment for a patient with infected sutures, presenting with erythema around the wound, who has not been adhering to their prescribed antibiotic regimen?

Treatment of Infected Sutures

For infected sutures presenting with erythema around the wound, the recommended treatment is suture removal plus incision and drainage, along with restarting the previously prescribed antibiotic regimen. 1

Initial Management

1. Suture removal:

   • Complete removal of all suture material is essential as sutures act as foreign bodies that can harbor bacteria and promote biofilm formation 1, 2
   • Suture material provides a surface for bacterial adherence and proliferation, contributing to surgical site infections 3

2. Incision and drainage:

   • If any purulent material is present, perform adequate drainage 1
   • Ensure thorough exploration of the wound to remove any debris or necrotic tissue

3. Wound care:

   • Clean the wound with appropriate antiseptic solution
   • Consider leaving the wound open if significant infection is present
   • Apply appropriate dressing based on wound characteristics

Antibiotic Therapy

1. Restart prescribed antibiotic:

   • Since the patient has not been taking the previously prescribed antibiotic as directed, restarting and emphasizing adherence is critical 4
   • Emphasize the importance of completing the full course of antibiotics even if symptoms improve 4

2. Antibiotic selection:

   • For surgical site infections on trunk or extremities away from axilla or perineum:
     • First-line options: Cephalexin 500 mg every 6 hours PO or Dicloxacillin (if MSSA is suspected) 1
     • For suspected MRSA: Trimethoprim-sulfamethoxazole or Doxycycline 1, 5
   • Duration of therapy should be 5-7 days, but may be extended if the infection has not improved 1

Patient Education

1. Medication adherence:

   • Explain that skipping doses or not completing the full course of therapy will:
     • Decrease the effectiveness of immediate treatment
     • Increase the likelihood of bacteria developing resistance 4, 5
   • Take antibiotics exactly as prescribed, even if symptoms improve before completion 4

2. Wound care instructions:

   • Proper cleaning and dressing techniques
   • Signs of worsening infection requiring immediate attention (increasing pain, swelling, redness, purulent drainage, fever)
   • Elevation of the affected area to reduce edema 1

Special Considerations

1. Hospitalization criteria:

   • Consider inpatient management if:
     • Patient shows signs of systemic inflammatory response syndrome (SIRS)
     • Poor adherence to therapy is likely to continue
     • Patient is immunocompromised
     • Outpatient treatment is failing 1

2. Wound culture:

   • Consider obtaining wound cultures if:
     • Infection appears severe
     • Patient has risk factors for resistant organisms
     • Previous antibiotic treatment has failed

Follow-up

1. Short-term follow-up (48-72 hours):

   • Assess response to treatment
   • Evaluate need for wound closure or continued open management
   • Reinforce importance of antibiotic adherence

2. Long-term considerations:

   • Address any underlying factors that may impair wound healing
   • Consider potential need for wound revision if healing is suboptimal

Common Pitfalls to Avoid

1. Not removing all infected suture material:

   • Bacterial colonization of sutures can persist even with antibiotic therapy 2, 6
   • Complete removal is necessary for effective treatment

2. Inadequate patient education about antibiotic adherence:

   • Clearly explain the consequences of non-adherence
   • Discuss potential barriers to adherence and address them

3. Failure to recognize deeper infection:

   • Be vigilant for signs of deeper tissue involvement requiring more aggressive intervention
   • Monitor for signs of systemic infection requiring hospitalization

4. Premature wound closure:

   • Infected wounds often benefit from being left open initially to allow drainage and prevent abscess formation

By following this approach, you can effectively manage infected sutures while reducing the risk of complications and recurrence.