What is the recommended management for surgical wound infections?

Management of Surgical Wound Infections

The cornerstone of surgical wound infection management is immediate suture removal plus incision and drainage, with systemic antibiotics reserved only for patients demonstrating significant systemic inflammatory response (fever >38.5°C, heart rate >110 bpm, WBC >12,000/µL, or erythema extending >5 cm from wound edge), immunocompromised status, or infections involving specific anatomical sites. 1, 2

Initial Surgical Management

All surgical site infections require prompt and wide opening of the surgical incision with drainage as the primary intervention. 1, 2

• Remove sutures completely and open the incision to evacuate all purulent material 1, 2
• Perform irrigation and debridement of devitalized tissue 1
• Continue dressing changes until the wound heals by secondary intention 2, 3
• Obtain Gram stain and culture of purulent material to guide targeted therapy, though empiric treatment can be initiated based on likely pathogens 2

Superficial incisional SSIs that have been adequately opened and drained can usually be managed without antibiotics. 1

When to Add Systemic Antibiotics

Antibiotics are indicated ONLY when specific criteria are met 1, 2:

• Temperature >38.5°C 1, 2
• Heart rate >110 beats/minute 1, 2
• White blood cell count >12,000/µL 1, 2
• Erythema and induration extending >5 cm from the wound edge 1, 2
• Signs of organ dysfunction (hypotension, oliguria, decreased mental alertness) 1
• Immunocompromised patients 1, 2

Antibiotic Selection Based on Surgical Site

Clean Procedures (Trunk, Head/Neck, Extremities)

For infections following clean operations where the GI, gynecologic, and respiratory tracts were not entered, Staphylococcus aureus is the usual pathogen 1:

For MSSA (Methicillin-Susceptible S. aureus):

• First-generation cephalosporin (cefazolin) or antistaphylococcal penicillin 1, 2
• Cefazolin dosing per FDA label for skin/soft tissue infections 4

For MRSA risk factors (nasal colonization, prior MRSA infection, recent hospitalization within 30 days, recent antibiotics, long-term care facility residence, age ≥75 years, hospitalization >16 days, prosthesis implantation, Charlson score >5) 1:

• Vancomycin, linezolid, daptomycin, telavancin, or ceftaroline 1, 2

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

These sites require coverage for gram-negative bacteria AND anaerobes 1, 2:

Combination regimens:

• Cephalosporin (ceftriaxone) or fluoroquinolone (ciprofloxacin/levofloxacin) PLUS metronidazole 1, 2

Single-drug alternatives:

• Piperacillin-tazobactam 2
• Carbapenems (imipenem, meropenem, ertapenem) 2

The pathogens in clean-contaminated or contaminated procedures are typically aerobic and anaerobic organisms from the normal endogenous microflora of the surgically resected organ 1.

Duration of Antibiotic Therapy

A brief course of 5-7 days is typically sufficient after adequate surgical drainage. 2, 3

• Do not extend beyond 7 days for most surgical site infections 2
• Longer courses may be needed only for complex infections or immunocompromised patients 2

Critical Pitfalls to Avoid

Do not routinely administer antibiotics for uncomplicated surgical site infections after adequate drainage - this is the most common error in management 2, 3:

• Antibiotics without proper surgical drainage when an abscess is present will fail 2
• Prolonged antibiotic courses beyond 7 days provide no benefit and increase harm 2, 5
• Do not confuse prophylaxis with treatment - if infection is established, this requires therapeutic antibiotics, not prophylactic dosing 5

Special Considerations

Groin procedures (hip prosthesis, vascular bypass) may be infected by gram-negative bacteria despite being "clean" procedures, due to enteric flora colonization of groin skin 1:

• Consider broader coverage even for clean groin procedures if infection develops 1

Early postoperative infections (within 48 hours) are almost always due to Streptococcus pyogenes or Clostridium species and require immediate aggressive management 1:

• These rare early infections mandate urgent surgical exploration and broad-spectrum antibiotics 1

Fascial disruption should always prompt immediate drainage, as deep incisional SSIs cause the most morbidity 1:

• Percutaneous drainage and negative pressure wound therapy are effective alternatives to open management 1