Management of Slow-Resolving Post-Surgical Wound Infection
Immediate Assessment and Decision Points
Continue flucloxacillin but extend the duration beyond the current 8 days, as the wound is showing improvement (better than 4-5 days ago) despite the recent fluctuation. 1 The key clinical finding is that the infection is responding—just slowly—which indicates the antibiotic is working but needs more time.
Critical Factors Supporting Continuation
- The wound is "very much better than four or five days ago" despite recent fluctuation, indicating the current antibiotic is effective but healing is protracted 1
- Surgical site infections (SSIs) in elderly patients, particularly facial wounds, commonly require extended courses beyond the typical 5-7 days due to impaired wound healing and local tissue trauma 2
- The serous drainage with temporary improvement followed by re-swelling suggests normal wound healing with inflammatory fluctuation, not treatment failure 2
Recommended Management Algorithm
1. Extend Antibiotic Duration
- Continue flucloxacillin 500mg QID for an additional 7-10 days (total 15-18 days from initiation) 2, 1
- For post-surgical facial SSIs showing slow but definite improvement, 7-14 days total therapy is standard, guided by clinical response 2, 1
2. Wound Care Optimization
- Open the wound if not already done—the most important therapy for SSI is incision evacuation of infected material 2
- Continue dressing changes until healing by secondary intention is complete 2
- Avoid premature wound closure, as this is a contaminated surgical site 2
3. Reassessment Triggers for Treatment Modification
Switch antibiotics ONLY if:
- Erythema extends >5cm beyond wound margins 2
- New systemic signs develop: temperature >38.5°C, heart rate >110 bpm 2
- Worsening rather than fluctuating swelling over the next 48-72 hours 1
- Signs of necrotizing infection: severe pain out of proportion, skin anesthesia, rapid progression, "wooden-hard" tissues 2, 1
If switching is needed:
- Add MRSA coverage with oral clindamycin 300-450mg QID if local resistance <10% 1
- Alternative: Augmentin 875/125mg BID for broader gram-positive and anaerobic coverage in facial wounds 2
4. Adjunctive Measures Often Overlooked
- Elevate the head of bed 30-45 degrees to promote gravitational drainage of facial edema 1
- Tetanus toxoid if not current (within 10 years for clean wounds, within 5 years for contaminated wounds) 2
- Ensure adequate nutrition and hydration to support wound healing in this elderly patient 2
Common Pitfalls to Avoid
- Do NOT reflexively switch antibiotics when the wound is showing overall improvement despite day-to-day fluctuation—this represents normal healing kinetics, not treatment failure 2, 1
- Do NOT add MRSA coverage empirically without specific risk factors (purulent drainage, penetrating trauma, known MRSA colonization) 1
- Do NOT close the wound prematurely—facial wounds are an exception for primary closure, but only with meticulous debridement and copious irrigation at the time of initial injury, not after established infection 2
- Do NOT stop antibiotics at 10 days based on tradition if clinical signs of infection persist—extend based on response 1
When to Hospitalize
- Development of systemic inflammatory response syndrome (SIRS): fever, tachycardia, hypotension, altered mental status 1
- Concern for deeper infection: orbital involvement, facial cellulitis extending beyond the surgical site 2
- Inability to take oral medications or ensure outpatient follow-up 1