What is the management for a patient with purulent discharge from the suture site after an appendicectomy?

Management of Purulent Discharge from Suture Site After Appendectomy

Purulent discharge from a suture site after appendectomy requires prompt wound care, local debridement, and appropriate antibiotic therapy based on the severity of infection, with most cases manageable through outpatient treatment.

Initial Assessment and Classification

When evaluating purulent discharge from a suture site after appendectomy, first determine the extent of infection:

• Superficial surgical site infection (SSI): Limited to skin and subcutaneous tissue
• Deep SSI: Involving deeper soft tissues (fascia, muscle)
• Organ/space SSI: Involving intra-abdominal space (abscess formation)

Management Algorithm

Step 1: Wound Care and Local Management

• Open the wound at the site of purulent discharge
• Perform local debridement of any necrotic tissue
• Drain any collections of pus
• Clean with sterile saline solution
• Consider wound swab for culture and sensitivity testing before starting antibiotics 1

Step 2: Antibiotic Therapy

• For superficial SSI with minimal systemic symptoms:

  • Oral antibiotics covering skin flora and enteric organisms
  • First-line options: Amoxicillin-clavulanate or cephalexin plus metronidazole 1
  • Duration: 5-7 days is typically sufficient 1

• For more extensive infection or systemic symptoms:

  • Consider initial IV antibiotics if fever, leukocytosis, or extensive cellulitis present
  • Options include:
    • Ampicillin-sulbactam
    • Ceftriaxone plus metronidazole
    • Piperacillin-tazobactam for more severe cases 1
  • Early switch (after 48 hours) to oral antibiotics when clinically improving 1

Step 3: Monitoring and Follow-up

• Daily wound care with dressing changes
• Assess for:
  • Decreasing purulent discharge
  • Reduction in surrounding erythema
  • Resolution of systemic symptoms
  • Development of granulation tissue
• Follow-up within 48-72 hours to reassess wound 2

Special Considerations

Intra-abdominal Abscess Suspicion

If there are signs suggesting a deeper infection (persistent fever, severe abdominal pain, significant leukocytosis):

• Obtain abdominal imaging (ultrasound or CT scan) 1
• If abscess identified:
  • Percutaneous image-guided drainage if accessible 2
  • Continue broad-spectrum antibiotics for 3-5 days after adequate source control 1

Prevention of Future Complications

• Avoid routine prophylactic use of intra-abdominal surgical drains after appendectomy as they provide no benefit in preventing surgical site infections 1, 2
• For future surgeries, consider:
  • Appropriate timing of preoperative antibiotics (within 60 minutes before incision) 1
  • Proper skin antisepsis techniques
  • Use of wound protectors during surgery 3

Common Pitfalls to Avoid

1. Prolonged antibiotic therapy: Extending antibiotics beyond 3-5 days does not improve outcomes when adequate source control is achieved 1

2. Delayed wound opening: Failing to open an infected wound promptly can lead to abscess formation and more extensive infection

3. Inadequate follow-up: Ensure proper wound care instructions and timely follow-up to monitor healing progress

4. Missing deeper infections: Always consider the possibility of intra-abdominal abscess in patients with persistent symptoms despite appropriate wound care

Outpatient vs. Inpatient Management

Most patients with superficial surgical site infections can be managed as outpatients with:

• Appropriate wound care
• Oral antibiotics
• Close follow-up

Consider inpatient management for:

• Systemic illness (high fever, significant leukocytosis)
• Failed outpatient management
• Suspicion of deep or organ/space infection
• Immunocompromised patients
• Inability to comply with outpatient wound care

Early discharge after appropriate initial management is safe and does not increase readmission rates 4, 5.