What is the best course of action for a patient (ptn) post appendectomy with an erythematous wound and serous discharge after removal of one stitch?

Management of Post-Appendectomy Erythematous Wound with Serous Discharge

Opening all the wound is the most appropriate management for a post-appendectomy patient with an erythematous wound and serous discharge after removal of one stitch. 1

Assessment and Initial Management

• The primary and most important therapy for surgical site infections (SSIs) is to open the incision, evacuate the infected material, and continue dressing changes until the wound heals by secondary intention 1
• Erythema around the wound with serous discharge after stitch removal strongly suggests early surgical site infection that requires intervention 1
• Physical appearance of the incision provides the most reliable information for diagnosis of SSI, with local signs of pain, swelling, erythema, and drainage usually present 1

Recommended Management Algorithm

1. Open the entire wound:

   • Complete opening of the wound is necessary to properly drain any infected material 1
   • This is considered the standard of care for managing suspected SSIs 1

2. Evacuate any infected material:

   • After opening the wound, any purulent or serous material should be drained 1
   • Consider obtaining cultures if purulent drainage is present 1

3. Implement regular dressing changes:

   • Continue dressing changes until the wound heals by secondary intention 1
   • Daily antiseptic dressings with agents such as povidone-iodine 10% are appropriate 2

Antibiotic Considerations

• If there is minimal surrounding evidence of invasive infection (<5 cm of erythema and induration), and if the patient has minimal systemic signs of infection (temperature <38.5°C and pulse rate <100 beats/min), antibiotics are unnecessary 1
• For patients with temperature >38.5°C or pulse rate >110 beats/minute or erythema extending beyond the wound margins for >5 cm, a short course (24-48 hours) of antibiotics may be indicated 1
• The single published trial of antibiotic administration for SSIs found no clinical benefit associated with this treatment for most cases 1
• Antibiotics may only offer advantage in post-appendectomy wound infections for cases of perforated appendix 2

Important Considerations

• Delayed primary skin closure is not recommended as it increases the length of hospital stay and overall costs in open appendectomies with contaminated/dirty wounds and does not reduce the risk of SSI 1
• Syringe pressure irrigation of the surgical wound after opening it can help decrease the incidence of postoperative wound infection in complicated cases 3
• Surgical site infections rarely occur during the first 48 hours after surgery, with fever during that period usually arising from non-infectious causes 1, 4
• By postoperative day 4, fever is equally likely to be caused by an SSI or by another infection or unknown sources 4

Follow-up Recommendations

• Daily wound inspection is essential to detect signs of infection early 4
• Regular dressing changes should continue until the wound shows signs of healing 1
• Early discharge is safe after proper wound management, with most patients able to return to full normal activities within 2 weeks 5, 6
• Patients should be instructed to return if they develop fever >38.5°C, increasing pain, spreading redness, or purulent discharge 1

Remember that opening the wound is the definitive management for this presentation, as it allows for proper drainage and promotes healing by secondary intention, which is the standard of care for surgical site infections following appendectomy.