What are the signs and prevention of surgical incision infection?

How to Explain a Possible Surgical Incision Infection to Patient

Surgical site infections require prompt identification and treatment through opening the incision and evacuating infected material, with antibiotics only necessary when systemic inflammatory signs are present or in immunocompromised patients. 1

Signs of Surgical Site Infection

Surgical site infections (SSIs) are classified according to their depth and severity:

• Superficial incisional SSI (most common type):

  • Redness, warmth, and swelling around the incision
  • Pain or tenderness at the incision site
  • Purulent drainage from the incision
  • Fever (temperature >38°C/100.4°F)
  • Diagnosis by surgeon based on clinical assessment 1

• Deep incisional SSI (more serious):

  • Affects deeper tissues beneath the incision
  • May cause more severe pain
  • Can lead to wound dehiscence (opening of the wound)
  • Often requires more aggressive intervention 1

• Organ/space SSI (most severe):

  • Infection involving organs or spaces manipulated during surgery
  • May present with systemic symptoms
  • Often requires drainage and more intensive treatment 1

When to Seek Medical Attention

Patients should contact their healthcare provider immediately if they notice:

• Increasing redness extending beyond the incision margins
• Purulent (pus) drainage from the wound
• Increasing pain at the surgical site
• Fever above 38°C (100.4°F)
• Wound opening or separation 1

Prevention Strategies

Before Surgery

• Antibiotic prophylaxis: Should be administered within 30-60 minutes before incision 2, 3
• Hair removal: If necessary, use electric clippers rather than razors (4.4% infection rate with razors vs. 2.5% with clippers) 2, 3
• Skin preparation: Use chlorhexidine gluconate and alcohol-based solutions (4.0% infection rate vs. 6.5% with povidone-iodine) 2, 3
• Decolonization: For high-risk procedures, consider nasal decolonization for Staphylococcus aureus carriers 2

During Surgery

• Maintain normothermia: Use active warming devices to keep body temperature above 36°C (4.7% infection rate with warming vs. 13% without) 1, 2, 3
• Use of triclosan-coated sutures: Significantly reduces SSI prevalence 1, 2
• Wound protectors: Dual-ring constructed wound protectors are superior to single-ring devices 1, 2
• Negative pressure wound therapy: Consider for high-risk wounds (9.7% infection rate with vs. 15% without) 1, 2, 3

After Surgery

• Wound care: Keep the incision clean and dry
• Monitor for signs of infection: Especially during the first 30 days after surgery
• Follow-up appointments: Attend all scheduled post-operative visits 2

Treatment Approach

1. For superficial incisional SSIs:

   • The most important treatment is opening the incision, evacuating infected material, and performing dressing changes until the wound heals by secondary intention 1
   • If erythema/induration is <5 cm and minimal systemic signs (temperature <38.5°C, WBC <12,000 cells/µL, pulse <100 beats/minute), antibiotics may be unnecessary 1

2. When antibiotics are needed:

   • For patients with systemic inflammatory response syndrome criteria (fever >38°C, tachycardia, tachypnea, abnormal WBC)
   • For immunocompromised patients
   • For patients with signs of organ failure (hypotension, oliguria, decreased mental alertness) 1

3. Choice of antibiotics:

   • For suspected MSSA: First-generation cephalosporin or antistaphylococcal penicillin
   • For suspected MRSA: Vancomycin, linezolid, daptomycin, telavancin, or ceftaroline
   • For infections following operations on the axilla, GI tract, perineum, or female genital tract: Agents active against gram-negative bacteria and anaerobes 1

Common Pitfalls to Avoid

• Delayed recognition: SSIs rarely occur during the first 48 hours after surgery. Fever during this period usually arises from non-infectious causes 1
• Inappropriate antibiotic use: Antibiotics should not be used routinely after surgery for prevention 1
• Inadequate debridement: The most important treatment for SSI is opening the incision and evacuating infected material 1
• Failure to consider risk factors: Age, comorbidities, smoking, obesity, malnutrition, immunosuppression, and wound contamination class all increase SSI risk 1
• Neglecting normothermia: Maintaining normal body temperature significantly reduces infection risk 1, 2, 3

By understanding these signs, prevention strategies, and treatment approaches, patients can better recognize potential surgical site infections and seek appropriate care promptly.