What is the next step in managing a patient with purulent discharge from a surgical wound 5 days after an appendectomy (appendix removal)?

Management of Purulent Wound Discharge 5 Days Post-Appendectomy

The next step is to explore the wound at the bedside (Option A), as this represents a superficial surgical site infection requiring immediate drainage and wound opening rather than imaging or antibiotics alone. 1, 2

Rationale for Wound Exploration

Purulent discharge from a surgical wound 5 days post-appendectomy is a superficial surgical site infection (SSI) that requires mechanical source control through wound opening and drainage. 1, 2 The World Society of Emergency Surgery guidelines emphasize that adequate source control is the cornerstone of managing post-appendectomy infections, and superficial wound infections are best managed by opening the wound to allow drainage. 1

Why Not CT Abdomen First?

• CT imaging is not indicated for superficial wound infections with obvious purulent discharge, as the diagnosis is clinical and the treatment is mechanical drainage. 1
• CT abdomen would be appropriate if you suspected a deep intra-abdominal abscess (presenting with persistent fever, leukocytosis, and abdominal pain without obvious wound infection), but not for superficial wound drainage. 3
• Imaging delays definitive treatment and increases costs without changing management for a superficial SSI. 1

Why Not Antibiotics Alone?

• Antibiotics without source control (wound drainage) are ineffective for established wound infections with purulent collections. 2
• A 2002 study specifically examining post-appendectomy wound infections found that parenteral antibiotics offered no advantage for wound infections except in cases of perforated appendicitis, and even then, mechanical drainage was essential. 2
• The World Society of Emergency Surgery guidelines emphasize that antibiotics are adjunctive to adequate source control, not a replacement for it. 1

Proper Management Algorithm

Immediate Steps:

1. Open the wound at the bedside to allow purulent drainage (remove skin sutures/staples as needed). 1, 2
2. Irrigate the wound with sterile saline or antiseptic solution (povidone-iodine 10%). 2
3. Pack the wound loosely with sterile gauze and plan for daily dressing changes. 2

Antibiotic Considerations:

• Add systemic antibiotics only if there are signs of spreading cellulitis, systemic infection (fever, leukocytosis), or if the original appendicitis was complicated/perforated. 1, 2
• For perforated appendicitis cases with wound infection, a study showed that parenteral antibiotics (metronidazole and cefoxitin) significantly reduced hospital stay and dressing frequency when combined with wound drainage. 2
• For uncomplicated appendicitis, wound drainage alone without antibiotics is typically sufficient. 1

When to Consider CT:

• Persistent fever and leukocytosis despite wound drainage suggests possible intra-abdominal abscess requiring imaging. 3
• Clinical deterioration or signs of deep infection (severe abdominal pain, peritoneal signs) warrant CT to rule out intra-abdominal collection. 3

Common Pitfalls to Avoid

• Do not delay wound exploration waiting for imaging when purulent discharge is obvious—this only prolongs infection and patient discomfort. 1, 2
• Do not rely on antibiotics alone for established wound infections with purulent collections, as this represents inadequate source control. 1, 2
• Do not assume all post-appendectomy infections are superficial—if the patient has persistent systemic symptoms after wound drainage, investigate for deeper collections. 3