What is the recommended treatment for wound surgical site infections?

Treatment of Surgical Site Infections

The primary treatment for surgical site infections is incision and drainage, with adjunctive systemic antibiotics indicated only when there are significant systemic signs of infection or specific anatomical considerations. 1

Initial Management

• Suture removal plus incision and drainage should be performed as the cornerstone treatment for all surgical site infections 1, 2
• Evaluate for systemic signs that would indicate need for antibiotics: temperature >38.5°C, heart rate >110 beats/minute, white blood cell count >12,000/μL, or erythema extending >5 cm from the wound edge 1, 2
• Gram stain and culture of purulent material are recommended to guide targeted antimicrobial therapy, though empiric treatment can be started based on likely pathogens 2

Antibiotic Selection Based on Surgical Site

Clean Operations on Trunk, Head, Neck, or Extremities

• For MSSA infections: First-generation cephalosporin (cefazolin) or antistaphylococcal penicillin 1, 3
• For suspected or confirmed MRSA: Vancomycin, linezolid, daptomycin, telavancin, or ceftaroline 1, 4
• The MRSA strains have shown 100% sensitivity to linezolid and tigecycline in some studies 5

Operations on Axilla, Gastrointestinal Tract, Perineum, or Female Genital Tract

• Agents active against gram-negative bacteria and anaerobes are required 1
• Options include:
  • Ceftriaxone or fluoroquinolone (ciprofloxacin/levofloxacin) plus metronidazole 1
  • Single-drug regimens: piperacillin-tazobactam or carbapenems (imipenem, meropenem, ertapenem) 1

Duration of Therapy

• A brief course of systemic antimicrobial therapy (5-7 days) is typically sufficient after adequate drainage 1, 2
• Longer courses may be needed for complex infections or immunocompromised patients 2

Special Considerations

Weight-Based Dosing for Vancomycin

• Standard 1g dosing of vancomycin is often inadequate; weight-based dosing at 15 mg/kg is recommended when vancomycin is used 6
• Underdosing of vancomycin may contribute to treatment failure and development of resistant strains 6

Renal Function Monitoring

• Dual antibiotic prophylaxis with cefazolin and vancomycin is associated with higher risk of acute kidney injury compared to cefazolin alone 7
• Monitor renal function closely when using vancomycin, particularly in patients with pre-existing kidney disease 7

Prevention of Recurrent Infections

• Identify and treat predisposing conditions such as edema, obesity, eczema, and venous insufficiency 1
• For patients with 3-4 episodes of infection per year despite treatment of predisposing factors, consider prophylactic antibiotics 1:
  • Oral penicillin or erythromycin twice daily for 4-52 weeks
  • Intramuscular benzathine penicillin every 2-4 weeks

Preventive Measures for Surgical Procedures

• Administer perioperative broad-spectrum intravenous antibiotics within 60 minutes before skin incision 1
• Use preoperative skin antisepsis with alcohol-based solutions or chlorhexidine for patients with alcohol allergies 1
• Consider use of fascial abdominal wound protectors, abdominal irrigation, and changing gloves and instruments before wound closure to reduce surgical site infections 1

Common Pitfalls to Avoid

• Do not routinely administer antibiotics for uncomplicated surgical site infections after adequate drainage 2
• Avoid prolonged antibiotic courses beyond 7 days for most surgical site infections 1, 2
• Do not rely solely on antibiotics without proper surgical drainage when an abscess is present 1, 2
• Be cautious with vancomycin use due to potential nephrotoxicity, especially when combined with other antibiotics 7