Management of Infected Wounds: Evidence‑Based Recommendations

1. Evidence Against Routine Use of Cadexomer Iodine

Large, high‑quality randomized controlled trials found no improvement in wound‑healing rates or infection prevention when iodine‑impregnated dressings were compared with standard non‑adherent dressings. [High‑quality RCT] [@2][@4][@3][@5]
An observer‑blinded RCT comparing carboxymethylcellulose hydrofibre, iodine‑impregnated dressing, and non‑adherent gauze showed no difference in healing at 24 weeks. [Well‑designed RCT] [@4][@5]
Studies specific to cadexomer iodine demonstrated no benefit in cavity wounds versus usual care. [@4][@5]
A Cochrane systematic review concluded there is no evidence that antiseptic preparations (including iodine) improve healing or prevent secondary infection in infected or contaminated wounds. [Systematic review] [@2][@3]

The 2024 American Heart Association/American Red Cross guidelines state it is reasonable to use running tap water or sterile saline for wound irrigation instead of antiseptic agents such as povidone‑iodine. [Guideline recommendation] [@1]
Multiple studies confirm that irrigation with povidone‑iodine provides no additional benefit over simple irrigation with tap water, boiled water, distilled water, or sterile saline. [@1]

The cornerstone of therapy is opening the incision, evacuating infected material, and performing dressing changes until the wound heals by secondary intention. [Clinical recommendation] [@6]
Thorough irrigation with running tap water or sterile saline should continue until no visible debris or foreign material remains. [@1]
Adequate debridement to remove devitalized tissue is essential. [@6][@7]
Deep tissue cultures (biopsy or curettage after cleansing) should be obtained before initiating antibiotics. [@7]
Systemic antibiotics should be prescribed based on infection severity and likely pathogens. [@7]

Antibiotics are not required when:
- Erythema/induration is < 5 cm around the wound, and
- Systemic signs are minimal (temperature < 38.5 °C, WBC < 12 000 cells/µL, pulse < 100 bpm). [@6]
- The wound is a superficial abscess that can be managed with incision and drainage alone. [@6]
Antibiotics are indicated when any of the following are present:
- Temperature > 38.5 °C or heart rate > 110 bpm. [@6]
- Erythema extending > 5 cm beyond wound margins. [@6]
- Animal or human bite wounds or any wound contaminated with saliva, which require immediate medical evaluation. [@1][@8]

In the absence of specific indications, choose the lowest‑cost dressing that maintains a moist environment and controls exudate. [@2][@3]
Occlusive dressings (e.g., film, petrolatum, hydrogel, cellulose/collagen) have been shown to promote better healing than dry dressings. [@1]
There is no evidence that antibiotic‑ or antibacterial‑impregnated dressings improve healing or reduce infection rates in clean wounds. [@1]

Do not rely on topical antiseptics alone; systemic antibiotics and proper wound care are required for infected wounds. [@6][@7]
Iodine preparations do not accelerate healing and perform no better than standard dressings. [@2][@4][@3][@5]
Never close infected wounds; they must heal by secondary intention after adequate drainage. [@6][@8]
Avoid first‑generation cephalosporins or macrolides for bite wounds because they have poor activity against Pasteurella multocida. [@8]