Management of Post-Appendectomy Erythematous Wound with Serous Discharge
Complete opening of the wound is necessary to properly drain any infected material and is the standard of care for managing suspected surgical site infections (SSIs). 1, 2
Assessment and Diagnosis
- The presentation of an erythematous wound with serous discharge after stitch removal strongly suggests an early surgical site infection that requires intervention 1
- Surgical site infections are diagnosed based on the presence of local signs including pain, tenderness, swelling, redness, and serous or purulent drainage 2
- Physical appearance of the incision provides the most reliable information for diagnosis of SSI, with local signs of erythema and drainage being key indicators 1
Recommended Management
- The primary therapy for surgical site infections is to open the incision completely, evacuate any infected material, and continue regular dressing changes until the wound heals by secondary intention 3
- After opening the wound, any purulent or serous material should be drained, and cultures should be obtained if purulent drainage is present 1
- Regular dressing changes should be performed until the wound heals by secondary intention 3
- Wound irrigation with antiseptic solutions such as 0.05% chlorhexidine gluconate may reduce SSI rates compared to saline irrigation, though this is not standard practice for all cases 4
Antibiotic Considerations
- If there is minimal surrounding evidence of invasive infection (erythema <5 cm from wound edges) and minimal systemic signs of infection (temperature <38.5°C, WBC count <12,000 cells/µL, and pulse <100 beats/minute), antibiotics are unnecessary 3, 2
- For patients with temperature >38.5°C, heart rate >110 beats/minute, or erythema extending >5 cm from the wound margins, a short course (24-48 hours) of antibiotics may be indicated in addition to opening the wound 3
- If antibiotics are needed, selection should be based on the site of surgery; for post-appendectomy wounds, agents active against gram-negative bacteria and anaerobes (such as a cephalosporin or fluoroquinolone in combination with metronidazole) are recommended 3
Important Considerations and Pitfalls
- 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 3
- Failure to recognize deeper infection can lead to inadequate treatment; 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 2
- Topical antiseptics (like povidone-iodine) have been shown to be toxic to healing tissue and should not be used on open wounds; topical antibiotic ointments are safer for open wounds 5
- Most superficial incisional SSIs can be managed with incision and drainage alone without antibiotics, avoiding unnecessary antibiotic use 2
Follow-up Recommendations
- Patients should be instructed to return if they develop fever >38.5°C, increasing pain, spreading redness, or purulent discharge 1
- Most patients can safely be managed as outpatients after appropriate wound opening and drainage, with early discharge being both feasible and safe 6, 7
- Follow-up within 1-2 weeks is recommended to assess wound healing progress 7