What is the treatment for an incision infection (surgical site infection)?

Treatment of Surgical Site Infections (Incision Infections)

The primary treatment for surgical site infections is suture removal plus incision and drainage. 1

Initial Management

• Suture removal plus incision and drainage should be performed for all surgical site infections 1
• Elevate the affected area and address predisposing factors such as edema or underlying cutaneous disorders 1
• Examine interdigital toe spaces in lower-extremity infections to identify and treat fissuring, scaling, or maceration that may harbor pathogens 1

Antibiotic Therapy

Systemic antimicrobial therapy is not routinely indicated for most surgical site infections after incision and drainage, but may be beneficial in specific circumstances:

Indications for Antibiotics:

• Significant systemic response (erythema and induration extending >5 cm from wound edge) 1
• Fever >38.5°C or heart rate >110 beats/min 1
• Signs of systemic toxicity or sepsis 1
• Immunocompromised patients 1
• Deep or necrotizing infections 1

Antibiotic Selection Based on Surgical Site:

1. Surgery of trunk or extremity away from axilla or perineum 1:

   • Oxacillin or nafcillin 2 g every 6 h IV
   • Cefazolin 0.5–1 g every 8 h IV
   • Cephalexin 500 mg every 6 h PO
   • SMX-TMP 160–800 mg PO every 6 h
   • Vancomycin 15 mg/kg every 12 h IV (if MRSA suspected)

2. Surgery of axilla or perineum 1:

   • Metronidazole 500 mg every 8 h IV plus one of:
     • Ciprofloxacin 400 mg IV every 12 h or 750 mg PO every 12 h
     • Levofloxacin 750 mg every 24 h IV
     • Ceftriaxone 1 g every 24 h

3. Surgery of intestinal or genitourinary tract 1:

   • Single-drug regimens:
     • Piperacillin-tazobactam 3.375 g every 6 h or 4.5 g every 8 h IV
     • Ertapenem 1 g every 24 h IV
     • Other carbapenems (imipenem, meropenem)
   • Combination regimens:
     • Ceftriaxone 1 g every 24 h + metronidazole 500 mg every 8 h IV
     • Ciprofloxacin + metronidazole

Special Considerations

• For suspected necrotizing infections, prompt surgical consultation is essential 1
• Empiric broad-spectrum antibiotics (vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem) should be started for severe infections with signs of systemic toxicity 1
• Tetanus toxoid should be administered to patients without toxoid vaccination within 10 years 1
• In patients with recurrent infections, identify and treat predisposing conditions such as obesity, venous insufficiency, and toe web abnormalities 1

Hospitalization Criteria

• Outpatient therapy is recommended for patients without SIRS, altered mental status, or hemodynamic instability 1
• Hospitalization is recommended for 1:
  • Concern for deeper or necrotizing infection
  • Poor adherence to therapy
  • Severely immunocompromised patients
  • Failing outpatient treatment

Common Pitfalls to Avoid

• Delaying incision and drainage, which is the cornerstone of treatment 1
• Overuse of antibiotics for simple incisional infections that only require drainage 1
• Failure to consider MRSA coverage in appropriate clinical settings 1
• Inadequate assessment for deeper infection or necrotizing fasciitis 1
• Not addressing underlying predisposing factors, which can lead to recurrence 1