What is the recommended assessment and management for an episiotomy (perineal incision) infection?

Assessment and Management of Episiotomy Infection

For episiotomy infections, prompt surgical drainage, wound debridement, and appropriate antibiotic therapy targeting mixed aerobic-anaerobic organisms are essential for effective treatment. 1

Clinical Assessment

• Evaluate for signs of infection including erythema, edema, pain, purulent discharge, wound dehiscence, and systemic symptoms (fever >38.5°C, tachycardia >100 beats/min) 1
• Assess the extent of infection - whether it's superficial or involves deeper tissues 1
• Determine if there is wound dehiscence with or without infection 2
• Check for systemic inflammatory response syndrome (SIRS) criteria or signs of organ failure 1
• Consider rare but serious complications like necrotizing fasciitis or clostridial myonecrosis, especially with severe pain, rapid progression, or systemic toxicity 1, 3

Diagnostic Approach

• Obtain wound cultures before initiating antibiotics to guide targeted therapy 1
• For severe or systemic infections, blood cultures may be warranted 1
• Consider imaging (ultrasound or CT) if deep space infection or abscess is suspected 1

Management Protocol

Surgical Management

• Open the infected wound promptly with incision and drainage as the primary intervention 1
• Perform thorough debridement of necrotic tissue 4
• For simple wound infections with minimal systemic symptoms, surgical drainage alone may be sufficient without antibiotics 1
• For dehisced wounds, options include:
  • Traditional approach: Leave open to heal by secondary intention 2
  • Alternative approach: Consider incision, curettage, and primary resuturing under antibiotic coverage for faster healing 4

Antibiotic Therapy

• For episiotomy infections with SIRS criteria, organ failure signs, or in immunocompromised patients, initiate antibiotics 1
• For perineal/episiotomy infections, recommended regimens include:
  • Metronidazole 500 mg IV every 8 hours PLUS one of the following: 1
    • Ciprofloxacin 400 mg IV every 12 hours (or 750 mg PO every 12 hours)
    • Levofloxacin 750 mg every 24 hours (IV or PO)
    • Ceftriaxone 1 g every 24 hours
• For severe infections or necrotizing infections, broader coverage is recommended: 1
  • Piperacillin-tazobactam plus vancomycin, OR
  • Carbapenem (imipenem, meropenem, or ertapenem), OR
  • Cefotaxime plus metronidazole plus clindamycin
• Duration of therapy typically 5-7 days, guided by clinical response 5

Preventive Measures

• For third and fourth-degree lacerations (OASIS), prophylactic antibiotics are recommended to prevent infection 1
• Options include:
  • First-generation cephalosporin (cefazolin 2g IV) 1
  • For penicillin-allergic patients: gentamicin 5 mg/kg plus clindamycin 900 mg or metronidazole 500 mg 1
  • Second-generation cephalosporin (cefoxitin 2g IV) 1
• For uncomplicated episiotomies, routine prophylactic antibiotics have not shown clear benefit in preventing infection 6, 5

Supportive Care

• Pain management with acetaminophen, NSAIDs, and sitz baths 1
• Stool softeners to prevent constipation and reduce strain on the perineal area 1
• Good perineal hygiene with gentle cleansing after toileting 1
• Early follow-up within two weeks to assess healing 1

Special Considerations

• Necrotizing infections require urgent surgical consultation, aggressive debridement, and broad-spectrum antibiotics 1
• For clostridial infections, consider adding penicillin to the regimen 1, 3
• The incidence of episiotomy infection is relatively low (0.48-2%) but can cause significant morbidity if not properly managed 4, 5
• Wound dehiscence without infection may not require antibiotics but needs appropriate wound care 2

Monitoring and Follow-up

• Daily wound assessment for signs of healing or worsening infection 1
• Adjust antibiotic therapy based on culture results and clinical response 1
• Consider specialized postpartum perineal clinic referral for complex cases 1
• Evaluate for complete healing before resuming sexual activity 1