In a patient with mild swelling, erythema, and increased pain and tenderness around a recent surgical incision, what is the most appropriate initial management: surgical exploration, discharge, intravenous antibiotics, or observation with wound culture?

Management of Mild Surgical Wound Infection

For a patient with mild swelling, erythema, and increased pain at a surgical wound site, the most appropriate initial management is observation with wound culture (Option D), provided there are no systemic signs of infection. 1, 2

Clinical Decision Framework

When to Withhold Antibiotics and Observe

The Infectious Diseases Society of America establishes clear criteria for when antibiotics are not indicated after wound drainage or in early surgical site infections 2:

• Temperature <38.5°C
• Heart rate <100-110 beats/minute
• Erythema and induration <5 cm from the wound edge
• WBC count <12,000 cells/µL
• No purulent drainage
• No systemic signs of toxicity 1, 2

If all these criteria are met, observation with proper wound care is sufficient. 2

Role of Wound Culture

Obtaining a wound culture is valuable when clinical suspicion of infection exists, as it provides information on causative pathogens and antibiotic susceptibility 1. However, a critical pitfall is relying on superficial wound swabs, which risk contamination with normal skin flora 1. If culture is performed, use the Levine technique (swab after wound cleansing, applying pressure to express fluid from deeper tissue) rather than superficial swabbing. 3, 4

When to Escalate to IV Antibiotics (Option C)

IV antibiotics become necessary only when systemic signs develop 1, 2:

• Temperature ≥38.5°C
• Heart rate ≥110 beats/minute
• Erythema extending >5 cm from wound margins with induration
• WBC count >12,000/µL
• Purulent drainage developing after initial management
• Signs of systemic toxicity 1, 2

A brief 24-48 hour course would be appropriate if these criteria emerge. 2 For MSSA, use first-generation cephalosporin or antistaphylococcal penicillin; for MRSA risk, use vancomycin, linezolid, or daptomycin 1.

When Surgical Exploration is Indicated (Option A)

Surgical exploration is reserved for severe infections with 1:

• Profound toxicity, fever, or hypotension despite antibiotics
• Skin necrosis with easy fascial dissection
• Gas in affected tissue
• Suspicion of necrotizing fasciitis or deep abscess 1

The saying "don't let the sun set on pus" applies when there is persistent purulent discharge or signs of deep infection requiring debridement. 1

Why Discharge (Option B) is Inappropriate

Discharging a patient with evolving wound infection symptoms without establishing a monitoring plan risks progression to severe infection 1. At minimum, routine follow-up within 48-72 hours is essential to assess wound healing. 5

Practical Management Algorithm

For mild surgical wound infection (the scenario described):

1. Examine the wound carefully for purulent drainage, extent of erythema, and signs of deeper involvement 1
2. Check vital signs and WBC to stratify severity 1, 2
3. If no systemic signs present: Observe with proper wound care (daily dressing changes), consider wound culture using proper technique, and arrange 48-72 hour follow-up 5, 2
4. If systemic signs develop: Initiate IV antibiotics and consider surgical consultation 1

Common Pitfalls to Avoid

• Ordering imaging for superficial infections: CT or ultrasound should be reserved for suspected deep collections >3 cm, not superficial surgical site infections 2
• Relying on superficial swabs: These frequently grow contaminants rather than true pathogens 1
• Premature wound closure: Infected wounds should heal by secondary intention with regular dressing changes 5, 2
• Overuse of antibiotics: Most superficial SSIs after adequate drainage do not require antibiotics unless systemic criteria are met 1, 2