Should I remove the sutures, leave the infected, dehisced wound open for drainage, change antibiotics, and refer the patient to general surgery for incision and drainage?

Management of Infected Sutured Wound with Dehiscence

Yes, you should remove the sutures immediately, perform incision and drainage, leave the wound open, change antibiotics to cover skin flora including MRSA, and refer to general surgery for formal I&D if the infection is severe or you are uncomfortable managing it.

Immediate Suture Removal and Drainage

• Suture removal plus incision and drainage is the definitive treatment for surgical site infections, as this addresses the source of infection by evacuating purulent material 1.
• Remove all sutures from the infected wound to allow adequate drainage of pus and prevent further tissue necrosis 1.
• The presence of pus and dehiscence indicates established infection that cannot heal with sutures in place 1.

Wound Management Strategy

• Primary wound closure is not recommended for infected wounds - the wound must be left open to heal by secondary intention after adequate debridement and drainage 1.
• Perform copious high-pressure irrigation to remove bacteria, foreign bodies, and purulent material from the wound 2.
• Debride any devitalized or necrotic tissue with a scalpel, as dead tissue impairs the wound's resistance to infection 2.
• Pack the wound loosely if there is significant depth to prevent premature surface closure and allow continued drainage 3.

Antibiotic Management

Change antibiotics to cover the most likely pathogens:

• For surgical site infections on trunk or extremities, empiric coverage should target Staphylococcus aureus (including MRSA) and Streptococcus species 1.
• First-line options include:
  • TMP-SMX 160-800 mg PO every 12 hours, OR
  • Doxycycline 100 mg PO twice daily 3
  • Clindamycin 300-450 mg PO three times daily (if local MRSA resistance <10%) 3
• For severe infections with systemic signs (temperature >38.5°C, heart rate >110 bpm, erythema >5 cm from wound edge, WBC >12,000), use IV vancomycin 15 mg/kg every 12 hours 1.
• If the wound is near the axilla, perineum, or involves GI/GU tract contamination, add anaerobic coverage with metronidazole 500 mg every 8 hours 1.

Indications for Surgical Referral

Refer to general surgery when:

• Signs of systemic toxicity are present (SIRS criteria, altered mental status, hemodynamic instability) 1.
• You suspect deeper infection, necrotizing fasciitis, or involvement of fascial planes 1.
• The wound requires extensive debridement beyond your comfort level 1.
• There is concern for abscess formation in difficult-to-drain areas 3.
• The patient is immunocompromised or has failed outpatient management 1.

Duration of Antibiotic Therapy

• Continue antibiotics for 5-7 days if systemic signs are present 1, 3.
• Antibiotics alone without adequate drainage will fail - source control through I&D is more important than antibiotic selection 3.
• Extend therapy to 7-14 days only if there are signs of spreading cellulitis or deep tissue involvement 3.

Common Pitfalls to Avoid

• Never attempt primary closure of an infected wound - this traps bacteria and leads to abscess formation or necrotizing infection 1.
• Do not rely on antibiotics alone without removing sutures and draining pus - inadequate source control is the most common cause of treatment failure 3.
• Obtain wound cultures before starting new antibiotics to guide therapy, especially in areas with high MRSA prevalence 3.
• Ensure tetanus prophylaxis is up to date (within 10 years) 1.