Management of Secondary Infection Post-Split-Thickness Skin Graft
Immediately initiate antimicrobial-impregnated dressing (0.2% polyhexamethylene biguanide) combined with negative-pressure wound therapy (NPWT) to salvage the graft while treating the infection, as this approach achieves 100% graft take even in contaminated wounds without requiring graft removal. 1
Initial Assessment and Pathogen Identification
- Obtain wound cultures to identify the causative organism(s), as secondary infections are commonly polymicrobial and most frequently involve Staphylococcus aureus and Streptococcus pyogenes 2
- Specifically culture for Candida species in nosocomial infections, burns, or chronic wounds, as fungal infections can cause graft rejection 3
- Assess for signs of graft failure: partial or complete graft loss, purulent drainage, erythema, and inadequate graft adherence 1
Primary Treatment Strategy: Salvage with AMD-NPWT
The optimal approach is to apply antimicrobial-impregnated dressing with NPWT rather than removing the graft, as this technique prevents infection, ensures adequate immobilization, and eliminates complications like hematoma or seroma formation. 1
- AMD-NPWT provides continuous antimicrobial coverage while maintaining optimal graft-to-wound contact 1
- This method is particularly effective in diabetic populations and contaminated wounds, with average healing times of 17 days for wounds averaging 57 cm² 4
- NPWT as a bolster demonstrates superior outcomes compared to traditional tie-over dressings or cotton bolsters 4
Antimicrobial Therapy Based on Organism
For Bacterial Infections:
Topical antibiotics should be first-line therapy when feasible, as they provide high concentrations at the infection site without systemic side effects or allergic reactions. 2
- Reserve systemic antibiotics for extensive infections or signs of systemic involvement 2
- When systemic therapy is required, use penicillinase-resistant semi-synthetic penicillins, first-generation cephalosporins, macrolides, or amoxicillin/clavulanate 2
For Candida Infections:
Apply topical nystatin 100,000 units/mL combined with mafenide acetate 25 mg in 500 cc normal saline for Candida-positive cultures, which effectively treats fungal infection while improving graft take. 3
- This regimen is simple, nontoxic, and economical for nosocomial Candida infections 3
- Continue treatment until wound infection symptoms regress and graft adherence improves 3
Critical Pitfalls to Avoid
- Do not immediately remove the graft upon detecting infection—AMD-NPWT can salvage infected grafts that would otherwise fail 1
- Inadequate immobilization is a primary cause of graft failure in infected wounds; NPWT addresses this mechanically while treating infection 1
- Missing fungal infections leads to persistent graft rejection despite appropriate antibacterial therapy 3
- In diabetic patients, expect slightly longer healing times (average 17 days) but excellent outcomes with proper NPWT bolstering 4