What is the recommended treatment for a patient with surgical incision cellulitis, considering their recent surgical history and potential history of respiratory infections or allergies?

Surgical Incision Cellulitis: Treatment Recommendations

For surgical incision cellulitis, promptly open and drain the wound, then add systemic antibiotics only if the patient has systemic inflammatory response syndrome (SIRS) criteria, signs of organ failure, or is immunocompromised. 1

Immediate Wound Management

Suture removal plus incision and drainage is mandatory for all surgical site infections. 1 The infected incision must be opened widely to allow adequate drainage, irrigation, and debridement if needed. 1 If fascial disruption is suspected during examination, formal drainage in the operating room should be performed immediately. 1

• Percutaneous drainage, wound irrigation, and negative pressure-assisted wound management are effective modern options that may reduce the need for complete open management. 1
• Once the infection has cleared with open management, the wound can be closed secondarily. 1

When to Add Systemic Antibiotics

Antibiotics are NOT routinely indicated for superficial incisional surgical site infections after adequate drainage. 1 However, empiric broad-spectrum antibiotic treatment should be initiated when any of the following are present:

• Any SIRS criteria (fever >38°C or <36°C, heart rate >90 bpm, respiratory rate >20/min, WBC >12,000 or <4,000 cells/mm³) 1
• Signs of organ failure: hypotension, oliguria, decreased mental alertness 1
• Immunocompromised status 1
• Erythema and induration extending >5 cm from the wound edge 1
• Incomplete source control after initial drainage 1
• Significant surrounding cellulitis 1

Antibiotic Selection Based on Surgical Site

The pathogen profile differs dramatically by anatomical location of the original surgery:

Clean Surgery (Trunk or Extremity Away from Axilla/Perineum)

These infections are typically caused by Staphylococcus aureus from skin flora. 1

Oral options:

• Cephalexin 500 mg every 6 hours 1
• Oxacillin or nafcillin 2 g every 6 hours IV (hospitalized patients) 1
• Cefazolin 0.5-1 g every 8 hours IV 1

If MRSA risk factors present (long-term care facility resident, hospitalization within 30 days, Charlson score >5, COPD, recent beta-lactam/carbapenem/quinolone use, age ≥75 years, current hospitalization >16 days, prosthesis implantation): 1

• Vancomycin 15 mg/kg every 12 hours IV 1
• SMX-TMP 160-800 mg every 6 hours orally 1

Surgery of Axilla or Perineum

These require coverage for mixed aerobic and anaerobic flora:

• Metronidazole 500 mg every 8 hours IV PLUS ciprofloxacin 400 mg IV every 12 hours (or 750 mg orally every 12 hours) 1
• Metronidazole 500 mg every 8 hours IV PLUS levofloxacin 750 mg every 24 hours IV 1
• Metronidazole 500 mg every 8 hours IV PLUS ceftriaxone 1 g every 24 hours 1

Surgery of Intestinal or Genitourinary Tract

These require broad-spectrum coverage for enteric gram-negative and anaerobic bacteria:

Single-drug regimens:

• Piperacillin-tazobactam 3.375 g every 6 hours or 4.5 g every 8 hours IV 1
• Ertapenem 1 g every 24 hours IV 1
• Meropenem 1 g every 8 hours IV 1

Combination regimens:

• Ceftriaxone 1 g every 24 hours + metronidazole 500 mg every 8 hours IV 1
• Levofloxacin 750 mg IV every 24 hours + metronidazole 500 mg every 8 hours IV 1

Treatment Duration

Treat for 5 days if clinical improvement has occurred; extend only if the infection has not improved within this timeframe. 1, 2, 3 This applies to both surgical site infections and surrounding cellulitis. 1, 2

Warning Signs Requiring Urgent Surgical Consultation

Prompt surgical consultation is mandatory for patients with: 1

• Aggressive infection with signs of systemic toxicity 1
• Suspicion of necrotizing fasciitis (severe pain out of proportion to exam, rapid progression, skin anesthesia, gas in tissue, bullous changes) 1, 2
• Gas gangrene 1

For these severe infections, initiate vancomycin or linezolid PLUS piperacillin-tazobactam (or a carbapenem) immediately while arranging emergent surgical debridement. 1, 2, 3

Adjunctive Measures

• Elevate the affected area to promote drainage and reduce edema 1, 2
• Treat predisposing factors: chronic edema, obesity, eczema, venous insufficiency, toe web abnormalities 1, 2
• Examine interdigital toe spaces for tinea pedis, as treating fissuring and maceration eradicates colonization and reduces recurrence 1, 2

Critical Pitfalls to Avoid

• Do not reflexively prescribe antibiotics for all surgical site infections—superficial incisional SSIs that have been adequately opened can usually be managed without antibiotics. 1
• Do not use antibiotics as a substitute for adequate drainage—source control is primary treatment. 1
• Do not continue postoperative antibiotic prophylaxis—there is no evidence supporting this practice for preventing SSIs. 1
• Do not delay surgical consultation if necrotizing infection is suspected, as these progress rapidly and require debridement. 1, 2