Treatment of Surgical Site Infections

Diagnosis and Treatment

The primary treatment for a red and hard incision site (surgical site infection) is prompt and wide opening of the surgical incision, as recommended by the World Journal of Emergency Surgery 1
A red and hard incision site likely represents a surgical site infection (SSI), which is diagnosed based on presence of purulent incisional drainage, local signs including pain, tenderness, swelling, redness, and induration, and diagnosis by the attending surgeon or physician, according to the Clinical Infectious Diseases guidelines 2
Systemic Inflammatory Response Syndrome (SIRS) criteria, signs of organ failure, temperature >38.5°C or heart rate >110 beats/minute, and erythema extending >5 cm from the wound edge are used to determine the severity of the infection 1, 3
For all incisional SSIs, the primary treatment is to open the incision, evacuate infected material, and continue dressing changes until the wound heals by secondary intention, as recommended by the Clinical Infectious Diseases guidelines 2, 3
Antibiotics are NOT routinely indicated for incisional SSIs, but should be added if SIRS criteria or signs of organ failure are present, the patient is immunocompromised, or if temperature >38.5°C or heart rate >110 beats/minute, according to the Clinical Infectious Diseases guidelines 1, 3

For trunk or extremity operations away from axilla/perineum, antibiotic options include oxacillin or nafcillin 2g every 6h IV, cefazolin 0.5-1g every 8h IV, and cephalexin 500mg every 6h orally, as recommended by the Clinical Infectious Diseases guidelines 3
For operations involving intestinal or genital tracts, single-drug options include piperacillin-tazobactam, ertapenem, or other broad-spectrum agents, and combination options include ceftriaxone + metronidazole or ciprofloxacin + metronidazole, according to the Clinical Infectious Diseases guidelines 3
For operations involving axilla or perineum, antibiotic options include metronidazole plus either ciprofloxacin, levofloxacin, or ceftriaxone, as recommended by the Clinical Infectious Diseases guidelines 3
If MRSA is suspected, vancomycin 15 mg/kg every 12h IV should be added, according to the Clinical Infectious Diseases guidelines 3

Most superficial incisional SSIs can be managed with incision and drainage alone without antibiotics, as recommended by the Clinical Infectious Diseases guidelines 2, 3
Delayed drainage can lead to progression of infection, and prompt opening of the incision is crucial, according to the Clinical Infectious Diseases guidelines 2
Failure to recognize deeper infection can lead to inadequate treatment, and any deep SSI that does not resolve in the expected manner after treatment should be investigated as a possible manifestation of a deeper organ/space infection, as recommended by the Clinical Infectious Diseases guidelines 2
Always assess for systemic signs that would indicate the need for antibiotics, according to the World Journal of Emergency Surgery guidelines 1
If antibiotics are needed, a short course (24-48 hours) is usually sufficient after adequate drainage, as recommended by the Clinical Infectious Diseases guidelines 3