What is the recommended treatment for a patient with a surgical incision infection?

Treatment of Surgical Incision Infection

The primary treatment for a surgical incision infection is prompt and wide opening of the surgical incision to evacuate infected material, with antibiotics reserved only for patients showing systemic signs of infection (SIRS criteria, organ failure), immunocompromise, or specific clinical indicators. 1, 2

Primary Treatment Approach

Incision and drainage is the cornerstone of management for all incisional surgical site infections (SSIs). 1, 2

• Open the incision promptly and widely to evacuate all infected material 1, 2
• Continue dressing changes until the wound heals by secondary intention 2
• Delayed drainage can lead to progression of infection and increased morbidity 2
• Most superficial incisional SSIs can be managed with incision and drainage alone without antibiotics 2

When to Add Antibiotics

Antibiotics are NOT routinely indicated for incisional SSIs after adequate drainage. 1, 2 Add antibiotic therapy only when ANY of the following criteria are present:

• Systemic Inflammatory Response Syndrome (SIRS) criteria or signs of organ failure (hypotension, oliguria, decreased mental alertness) 1, 2
• Temperature >38.5°C or heart rate >110 beats/minute 2
• Erythema extending >5 cm from the wound edge 2
• Immunocompromised patient status 1, 2

Antibiotic Selection (When Indicated)

For Clean Procedures (Trunk/Extremity Away from Axilla/Perineum):

The most common pathogen is Staphylococcus aureus from skin flora 1

First-line options:

• Cefazolin 0.5-1g every 8 hours IV 2
• Oxacillin or nafcillin 2g every 6 hours IV 2
• Cephalexin 500mg every 6 hours orally 2

If MRSA is suspected (based on risk factors: long-term care facility residence, hospitalization within 30 days, Charlson score >5, age ≥75 years, current hospitalization >16 days, prosthesis implantation):

• Add vancomycin 15 mg/kg every 12 hours IV 1, 2

For Clean-Contaminated/Contaminated Procedures (Involving Intestinal or Genital Tracts):

Aerobic and anaerobic pathogens from endogenous microflora are most common 1

Single-drug options:

• Piperacillin-tazobactam 2
• Ertapenem 2

Combination options:

• Ceftriaxone + metronidazole 2
• Ciprofloxacin + metronidazole 2

For Operations Involving Axilla or Perineum:

Gram-negative bacteria and enteric flora may be present 1

• Metronidazole plus either ciprofloxacin, levofloxacin, or ceftriaxone 2

Duration of Antibiotic Therapy

• A short course of 24-48 hours is usually sufficient after adequate drainage 2
• Continue antibiotics only until systemic signs resolve 2
• There is no evidence to support prolonged postoperative antibiotic prophylaxis 1

Critical Pitfalls to Avoid

Common errors that worsen outcomes:

• Treating with antibiotics alone without opening the incision - this leads to treatment failure and progression of infection 2
• Delaying surgical drainage - prompt opening is crucial to prevent deeper tissue involvement 2
• Failing to recognize deeper infection - any deep SSI that does not resolve as expected should be investigated as a possible organ/space infection 2
• Using antibiotics routinely for all incisional SSIs - this contributes to antibiotic resistance without improving outcomes in uncomplicated cases 1, 2
• Continuing prophylactic antibiotics postoperatively - there is no evidence supporting this practice 1

Assessment for Severity

Evaluate every patient for these specific indicators:

• Temperature, heart rate, blood pressure 2
• Mental status changes 1, 2
• Urine output 1
• Extent of erythema (measure distance from wound edge) 2
• Immune status (diabetes, malnutrition, obesity, smoking, age) 1