What is the management for a patient with a gaping wound and purulent discharge one month after a Lower Segment Caesarean Section (LSCS)?

Management of Post-LSCS Wound Infection with Gaping and Purulent Discharge

This patient requires immediate surgical debridement with complete drainage of purulent material, followed by culture-directed antibiotic therapy for a minimum of 2 weeks, as purulent discharge is diagnostic of surgical site infection and mandates both source control and antimicrobial treatment. 1

Immediate Assessment and Intervention

Confirm Surgical Site Infection

• Purulent discharge from the wound is diagnostic of surgical site infection and requires no further confirmation 1
• Assess for spreading erythema extending >5 cm from the incision edge, which indicates more severe infection 1
• Check for systemic signs including fever >38.5°C, tachycardia >100 bpm, or hypotension suggesting septic shock 1
• Examine for wound dehiscence or breakdown of the suture line 1

Surgical Debridement - "Don't Let the Sun Set on Pus"

• Perform immediate surgical debridement with complete drainage of all purulent and infected material 2
• This is the cornerstone of sepsis control and must not be delayed 2
• Remove any necrotic or devitalized tissue during debridement 2
• Obtain deep tissue specimens (not superficial swabs) for culture and sensitivity during debridement 2, 3

Critical Pitfall: Do not rely on superficial wound swabs as they frequently grow colonizing organisms rather than true pathogens and lead to inappropriate antibiotic selection 2, 3

Microbiological Evaluation

Obtain Proper Cultures

• Take deep tissue specimens during surgical debridement, not superficial swabs 2, 3
• Common organisms in post-cesarean wound infections include Staphylococcus epidermidis (29%), Enterococcus faecalis (17%), Staphylococcus aureus (17%), Escherichia coli (11%), and Proteus mirabilis (10%) 4
• Most infections are polymicrobial, particularly those developing 4-6 days postpartum 1

Antibiotic Therapy

Empiric Coverage

• Initiate broad-spectrum antibiotics covering both vaginal and bowel flora immediately after obtaining cultures 2
• Use a second- or third-generation cephalosporin plus metronidazole, with consideration of adding gentamicin 2
• For penicillin allergy, use clindamycin as an alternative 2

Duration and Adjustment

• Continue antibiotics for a minimum of 2 weeks for severe soft tissue infection 2
• Narrow antibiotic spectrum based on culture results and clinical response 2
• Do not continue empiric antibiotics indefinitely without addressing the underlying surgical pathology 3

Wound Management After Debridement

Post-Debridement Care

• Leave the wound open to heal by secondary intention after debridement 2
• Keep the area clean and dry 5
• Monitor daily for signs of persistent or worsening infection (increased pain, redness, warmth, swelling, or continued purulent drainage) 5, 1

Dressing Management

• Use foam dressings rather than gauze to reduce local skin irritation, as foam lifts drainage away from the skin 2
• For peristomal leakage or drainage, apply zinc oxide-based skin protectants to surrounding skin 2
• Change dressings as needed based on drainage volume 2

Exclude Life-Threatening Complications

Screen for Necrotizing Fasciitis

• If infection developed within 48 hours postpartum with severe pain and systemic toxicity, suspect Group A Streptococcus or Clostridium species 1
• Look for rapidly spreading necrosis, crepitus (gas in tissues), bullae with reddish-blue fluid, or bronze-to-purplish skin discoloration 1
• These findings require immediate surgical exploration and aggressive debridement 1

Assess for Fascial Dehiscence

• Examine for fascial dehiscence, which occurs in approximately 0.3% of cases and requires surgical repair 4
• This is more likely with emergency cesarean delivery and morbid obesity 4

Follow-Up and Monitoring

Short-Term Follow-Up

• Reassess wound daily during initial treatment phase 2
• Ensure clinical improvement within 48-72 hours of debridement and antibiotic initiation 2
• If no improvement, consider repeat debridement and reassess antibiotic coverage based on culture results 2

Long-Term Wound Healing

• Most wounds will heal by secondary intention over several weeks 2
• Consider advanced wound therapies (negative pressure wound therapy, bioengineered skin equivalents) if the wound fails to show ≥50% reduction in size after 4 weeks of optimal management 3

Critical Pitfall: Do not delay surgical intervention in favor of antibiotics alone—source control through debridement is essential and must precede or accompany antibiotic therapy 2, 3