Treatment of Red and Hard Incision Site (Surgical Site Infection)
The primary treatment for a red and hard incision site (surgical site infection) is prompt and wide opening of the surgical incision. 1
Diagnosis of Surgical Site Infection
A red and hard incision site likely represents a surgical site infection (SSI), which is diagnosed based on:
- Presence of purulent incisional drainage 1
- Local signs including pain, tenderness, swelling, redness (erythema), and induration (hardness) 1
- Diagnosis by the attending surgeon or physician 1
Treatment Algorithm
Step 1: Assess Severity
Determine if any of these systemic signs are present:
- Systemic Inflammatory Response Syndrome (SIRS) criteria 1
- Signs of organ failure (hypotension, oliguria, decreased mental alertness) 1
- Temperature >38.5°C or heart rate >110 beats/minute 1
- Erythema extending >5 cm from the wound edge 1
Step 2: Primary Treatment
- For all incisional SSIs: Open the incision, evacuate infected material, and continue dressing changes until the wound heals by secondary intention 1
- Suture removal plus incision and drainage should be performed 1
Step 3: Determine Need for Antibiotics
Antibiotics are NOT routinely indicated for incisional SSIs 1
Antibiotics should be added ONLY if:
- Any SIRS criteria or signs of organ failure are present 1
- Patient is immunocompromised 1
- Temperature >38.5°C or heart rate >110 beats/minute 1
- Erythema extending >5 cm from wound margins 1
Step 4: Antibiotic Selection (if needed)
Base antibiotic selection on the surgical site:
For trunk or extremity operations away from axilla/perineum:
- Oxacillin or nafcillin 2g every 6h IV
- Cefazolin 0.5-1g every 8h IV
- Cephalexin 500mg every 6h orally 1
For operations involving intestinal or genital tracts:
- Single-drug options: Piperacillin-tazobactam, ertapenem, or other broad-spectrum agents
- Combination options: Ceftriaxone + metronidazole or ciprofloxacin + metronidazole 1
For operations involving axilla or perineum:
- Metronidazole plus either ciprofloxacin, levofloxacin, or ceftriaxone 1
If MRSA is suspected:
- Add vancomycin 15 mg/kg every 12h IV 1
Important Considerations and Pitfalls
Pitfall #1: Unnecessary antibiotic use. Most superficial incisional SSIs can be managed with incision and drainage alone without antibiotics 1
Pitfall #2: Delayed drainage. The most important therapy is to open the incision promptly; delaying this intervention can lead to progression of infection 1
Pitfall #3: Failure to recognize deeper infection. Any deep SSI that does not resolve in the expected manner after treatment should be investigated as a possible manifestation of a deeper organ/space infection 1
Pitfall #4: Missing systemic signs. Always assess for systemic signs that would indicate need for antibiotics 1
Pitfall #5: Inappropriate antibiotic duration. If antibiotics are needed, a short course (24-48 hours) is usually sufficient after adequate drainage 1
Additional Management Strategies
- Elevation of the affected area if applicable 1
- Treatment of predisposing factors such as edema or underlying cutaneous disorders 1
- For patients with recurrent infections, identify and treat predisposing conditions such as obesity, eczema, or venous insufficiency 1
Special Circumstances
For suspected necrotizing infections (rapidly spreading, severe pain, crepitus, bullae, skin necrosis, or signs of systemic toxicity): Obtain prompt surgical consultation and start broad-spectrum antibiotics immediately 1
For surgical site infections after implantation of prosthetic material: Consider more aggressive antibiotic therapy and possible removal of the implant depending on infection severity 1