What is the recommended treatment for an infected wound?

Treatment of Infected Wounds

The most important therapy for an infected wound is to open the incision, evacuate the infected material, and continue dressing changes until the wound heals by secondary intention, with antibiotics reserved for specific indications. 1

Initial Assessment and Management

• Proper wound cleansing and debridement of devitalized tissue are essential first steps in managing infected wounds 1
• Careful inspection of the wound is necessary to determine the extent of infection and guide treatment decisions 1
• Obtain appropriate specimens for culture before starting antibiotic therapy to guide targeted treatment 1
• Surgical consultation is recommended for aggressive infections with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene 1

Antibiotic Therapy Guidelines

When to Use Antibiotics

• Antibiotics are unnecessary if there is <5 cm of erythema and induration, and minimal systemic signs of infection (temperature <38.5°C, WBC count <12,000 cells/µL, pulse <100 beats/minute) 1
• Patients with temperature >38.5°C, heart rate >110 beats/minute, or erythema extending beyond wound margins for >5 cm may require a short course (24-48 hours) of antibiotics 1
• Clinically uninfected wounds should not be treated with antibiotics 1

Antibiotic Selection

For mild skin and soft tissue infections:

• First-choice options: Amoxicillin-clavulanic acid, cloxacillin, or cefalexin 1
• Duration: 1-2 weeks is usually sufficient for mild infections 1

For moderate to severe infections:

• Empiric treatment should be broad as etiology can be polymicrobial or monomicrobial 1
• Vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem, or ceftriaxone and metronidazole for severe infections 1
• Duration: 2-3 weeks for moderate to severe infections 1

For specific pathogens:

• Streptococcal infections: Penicillin plus clindamycin 1
• Staphylococcal infections: Nafcillin, oxacillin, cefazolin, vancomycin, or clindamycin 1
• Clostridial infections: Clindamycin plus penicillin 1

Special Considerations

Animal and Human Bites

• For animal bites: Amoxicillin-clavulanic acid orally; for intravenous treatment, ampicillin-sulbactam or piperacillin-tazobactam 1
• For human bites: Amoxicillin-clavulanic acid or ampicillin-sulbactam 1
• Tetanus prophylaxis should be administered if vaccination is not current within 10 years 1

Diabetic Foot Infections

• Uninfected diabetic wounds should not receive antibiotics 1
• For mild diabetic foot infections: Dicloxacillin, clindamycin, cefalexin, or amoxicillin-clavulanic acid 1
• For moderate to severe diabetic foot infections: Broader spectrum antibiotics such as levofloxacin, ceftriaxone, ampicillin-sulbactam, or ertapenem 1
• Antibiotic therapy should be combined with appropriate wound care and debridement 1

Surgical Site Infections (SSIs)

• For SSIs after clean procedures: Cefazolin, cefalexin, or vancomycin if MRSA is suspected 1
• For SSIs after procedures involving intestinal or genital tracts: Piperacillin-tazobactam, carbapenems, or combination of ceftriaxone and metronidazole 1

Wound Care Principles

• The most important therapy for an infected wound is opening the incision, evacuating infected material, and continuing dressing changes until healing occurs 1
• No specific type of dressing has been proven superior for preventing or treating wound infections 1
• Wounds should be cleansed with sterile normal saline (no need for iodine or antibiotic-containing solutions) 1
• Primary wound closure is not recommended for infected wounds, except for facial wounds which should be managed with copious irrigation, cautious debridement, and preemptive antibiotics 1

Common Pitfalls to Avoid

• Closing infected wounds, which can lead to abscess formation and delayed healing 1
• Overuse of antibiotics for wounds that can be managed with proper debridement and wound care alone 1
• Failing to obtain appropriate cultures before starting antibiotic therapy 1
• Not recognizing the signs of severe infection requiring urgent surgical intervention 1
• Continuing antibiotics beyond resolution of infection signs, which is unnecessary and may contribute to antibiotic resistance 1

By following these evidence-based guidelines, clinicians can effectively manage infected wounds while minimizing unnecessary antibiotic use and optimizing patient outcomes.