What medications should be given after suturing a wound?

Medications After Suturing a Wound

Primary Recommendation

Most simple, clean sutured wounds do not require prophylactic antibiotics—only topical antibiotic ointment (bacitracin or triple antibiotic) applied 2-3 times daily and tetanus prophylaxis when indicated. 1

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Topical Antibiotic Application

Apply topical bacitracin or triple antibiotic ointment (neomycin/polymyxin B/bacitracin) to all sutured wounds 2-3 times daily until healed. 2, 3

• Topical antibiotics reduce surgical site infection rates by approximately 40% compared to no treatment (RR 0.61,95% CI 0.42-0.87), preventing 20 infections per 1000 wounds treated. 4
• Bacitracin alone or triple antibiotic ointment are equally effective, with infection rates of 5.5% and 4.5% respectively, compared to 17.6% with petrolatum alone. 2
• Triple antibiotic ointment eliminates bacterial contamination within 16-24 hours and accelerates healing (mean 9 days vs longer with antiseptics). 3
• Apply ointment immediately after wound cleaning and redressing. 2

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Tetanus Prophylaxis

Administer tetanus toxoid to any patient without vaccination within the past 10 years. 5

• Tdap (tetanus-diphtheria-pertussis) is preferred over Td if the patient has never received Tdap. 5
• For dirty or contaminated wounds, consider tetanus immunoglobulin if the patient is unvaccinated or incompletely vaccinated. 5

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Systemic Antibiotics: When NOT Indicated

Do not prescribe oral or parenteral antibiotics for routine clean wounds—this increases antibiotic resistance without benefit. 1, 6

• A controlled trial showed that prophylactic systemic antibiotics (penicillin or tetracycline) actually resulted in higher infection rates (23%) compared to no antibiotics (7%) in minor sutured wounds. 6
• Simple clean wounds have infection rates of only 1% with proper wound care alone. 1

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Systemic Antibiotics: When INDICATED

Prescribe oral antibiotics for 3-5 days only in high-risk wounds: 5, 1

High-Risk Criteria Requiring Antibiotics:

• Immunocompromised patients 5, 1
• Asplenic patients 5
• Advanced liver disease 5
• Significant wound contamination 1
• Moderate to severe injuries, especially hand or face 5, 1
• Penetration of periosteum or joint capsule 5, 1
• Preexisting or resultant edema of affected area 5, 1

First-Line Antibiotic Selection:

For high-risk clean wounds: Amoxicillin-clavulanate 875/125 mg orally twice daily for 3-5 days. 5, 1

• This provides coverage against both aerobic and anaerobic bacteria. 5
• For animal or human bites: Amoxicillin-clavulanate remains first-line due to coverage of Pasteurella species and Eikenella corrodens. 1

For contaminated/dirty wounds (Class III/IV): Use therapeutic antibiotics, not prophylaxis. 5, 1

• First-generation cephalosporin (cefazolin 1-2g IV every 8 hours) for Staphylococcus aureus and streptococci coverage. 1, 7
• Add aminoglycoside (gentamicin) for severe injuries with gram-negative risk. 1

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Critical Timing Considerations

When systemic antibiotics are indicated, start them as soon as possible—ideally within 60 minutes of wound closure. 5, 1

• Delaying antibiotics beyond 3 hours significantly increases infection risk in contaminated wounds. 1
• For open fractures or severely contaminated wounds, antibiotics should be started immediately upon presentation and continued for 3 days (minor contamination) or 5 days (severe contamination). 5

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Management of Established Infection

If infection develops postoperatively with systemic signs (fever ≥38.5°C, tachycardia ≥100 bpm, or cellulitis >5 cm), open the suture line for drainage and prescribe antibiotics for 24-48 hours. 7

• Cefazolin, cefalexin, or cloxacillin for staphylococcal/streptococcal coverage. 1, 7
• Vancomycin 15-20 mg/kg IV every 8-12 hours if MRSA is suspected. 7
• Obtain wound cultures before starting antibiotics and adjust based on results. 7

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Common Pitfalls to Avoid

• Do not prescribe systemic prophylactic antibiotics for simple clean wounds—this increases resistance without reducing infection rates. 1, 6
• Do not extend antibiotic therapy beyond 5 days unnecessarily—this increases resistance risk without additional benefit. 1
• Do not use silver sulfadiazine on sutured wounds—it had a 12.1% infection rate compared to 5.5% with bacitracin in one trial. 2
• Do not substitute systemic antibiotics for proper wound irrigation, debridement, and closure technique—antibiotics are adjunctive only. 5
• Avoid using topical neomycin-containing products in patients with known allergies, though allergic contact dermatitis rates are low. 4