What is the treatment for an infected episiotomy (perineal incision) stitch?

Treatment of Infected Episiotomy Stitches

The primary and most critical treatment for an infected episiotomy is prompt surgical opening of the wound to evacuate infected material, with antibiotics reserved only for patients showing systemic signs of infection (fever >38.5°C, heart rate >110 bpm, erythema extending >5 cm from wound edge) or those who are immunocompromised. 1, 2

Immediate Surgical Management

Open the infected wound widely and evacuate all purulent material—this is the definitive treatment. 1, 2 The evidence is clear that drainage alone is sufficient for most episiotomy infections without systemic involvement. 1

• Continue dressing changes until the wound heals by secondary intention 1, 2
• Obtain wound cultures before initiating any antibiotics to guide targeted therapy 2
• Consider debridement if necrotic tissue is present 2

When to Add Antibiotics

Antibiotics are NOT routinely needed for simple wound infections after adequate drainage. 1 However, add antibiotics when ANY of the following are present:

• Temperature ≥38.5°C or pulse rate ≥100-110 beats/minute 1, 2
• Erythema extending >5 cm from the wound edge 2
• Signs of systemic inflammatory response syndrome (SIRS) or organ dysfunction 2
• Immunocompromised status 2

If antibiotics are indicated, use a short course of 24-48 hours after adequate drainage. 1

Antibiotic Selection for Perineal Infections

For episiotomy infections involving the perineum (which involves mixed aerobic-anaerobic flora from the genital tract):

First-line regimens:

• Metronidazole PLUS ciprofloxacin 2
• Levofloxacin 2
• Ceftriaxone 2
• Cefoxitin 1
• Ampicillin-sulbactam 1

For severe or necrotizing infections (rare but life-threatening):

• Piperacillin-tazobactam PLUS vancomycin 2
• Carbapenem-based regimens 1, 2
• Add penicillin if clostridial infection suspected 2

The choice of broader coverage is critical because perineal infections have mixed gram-positive, gram-negative, and anaerobic organisms. 1 In settings with high methicillin-resistant Staphylococcus aureus (MRSA) rates, consider adding vancomycin, daptomycin, or linezolid pending culture results. 1

Supportive Care Measures

• Manage pain with acetaminophen and NSAIDs 1, 2
• Use sitz baths for comfort and wound hygiene 2, 3
• Prescribe stool softeners (polyethylene glycol or mineral oil) to prevent constipation and reduce perineal strain 1, 2
• Maintain meticulous perineal hygiene with gentle cleansing after toileting 2

Critical Warning Signs Requiring Urgent Intervention

Necrotizing fasciitis is a rare but devastating complication that requires immediate recognition. 2 Look for:

• Rapidly spreading erythema beyond the immediate wound area
• Severe pain disproportionate to physical findings
• Skin discoloration, bullae, or crepitus
• Systemic toxicity with hypotension or altered mental status

These patients require urgent surgical consultation, aggressive debridement, and broad-spectrum antibiotics (piperacillin-tazobactam, meropenem, or imipenem PLUS clindamycin or metronidazole). 1, 2

Follow-Up and Monitoring

• Schedule early follow-up within two weeks to assess healing 1, 2
• Assess wounds daily for signs of healing or worsening infection 2
• Adjust antibiotic therapy based on culture results and clinical response 2
• Refer complex cases to a specialized postpartum perineal clinic 1, 2
• Evaluate for complete healing before resuming sexual activity 2

Common Pitfalls to Avoid

Do not prescribe antibiotics without opening the wound first—this is ineffective and delays proper treatment. 1 Studies of subcutaneous abscesses found no benefit for antibiotics when combined with drainage, and the single published trial of antibiotic administration for surgical site infections found no clinical benefit. 1

Do not miss deeper infections—if the wound does not resolve as expected after drainage, investigate for possible deeper organ/space infection or occult rectal injury. 1, 4 A digital rectal examination should be performed if there is any concern for extension into deeper tissues. 1

Recognize that episiotomy infections can extend—while rare, infection can lead to dehiscence with rectal injury requiring diverting ostomy. 4 Early recognition and thorough evaluation are essential to exclude occult rectal injury. 4