CHAPTER 222 Prevention and Treatment of Wound Infections
Initial Wound Management
After ensuring that the patient is medically stable, treatment of any wound should begin with hemostasis and a thorough physical examination, with particular attention to motor, sensory, and vascular components. The wound should be anesthetized and copiously irrigated, and any devitalized tissue should be débrided. Use a 30-mL syringe with a large-bore needle (16 to 18 gauge), with a steady, firm force. For large wounds, use at least 500 mL of fluid. A quick method is to hook up a three-way stopcock to a bag of saline. Clean wounds do not need irrigation. However, if there is significant manipulation of a wound (e.g., difficult removal of a deep lesion) or if a cyst has been ruptured during removal, irrigation will help remove small pieces of adipose or cystic contents. In the Cochrane Review “Water for Wound Cleansing” (Fernandez and Griffiths, 2008), tap water is determined to be as safe as sterile water or saline for this irrigation. If the possibility of a retained foreign body exists, a radiograph should be considered (see Chapter 22, Laceration and Incision Repair, for more details). Most wounds can be closed for up to 12 hours from the time of injury. The American College of Emergency Physicians (ACEP) guidelines recommend no more than 8 to 10 hours from injury to closure and less time (6 hours or less is optimal) for wounds of the hands and feet; however, clinical judgment may allow the time in the lowest-risk wounds to extend up to 20 hours. Clean superficial wounds on the head and neck can be safely closed for up to 12 hours or longer in healthy patients. Grossly contaminated wounds and most wounds older than 12 hours should be allowed to heal by secondary intention or undergo delayed closure in 4 to 5 days. Puncture wounds should not be closed. Buried absorbable subcutaneous sutures increase the infection rate in irrigated contaminated wounds and should be avoided. Shaving of wound sites should be avoided if possible because it increases the likelihood of infection.
Patient Factors
Certain patient or wound characteristics are associated with a possible increase in wound infection. When these higher-risk situations apply, there is little evidence to guide the practitioner’s decision to use or not use prophylaxis. Conditions to consider are listed in Box 222-1. All of these conditions or characteristics can increase the risk of infection. The use of the antibiotic itself carries the risk of allergic reactions, development of resistant organisms, antibiotic-associated colitis, fungal superinfections, and increased costs to the medical system. A careful assessment of risk and potential benefit should be made before making the choice.
Wound Factors
Prophylaxis in Clean Surgical Wounds
The use of prophylactic antimicrobials is not indicated in the vast majority of dermatologic procedures. In certain patient types and in some wound locations, antimicrobial prophylaxis may be indicated (see Box 222-1). If an antibiotic is indicated, the most common regimen for adults is a first-generation cephalosporin in a dose of 1 g given orally. Clindamycin 300 mg orally is the alternative for allergic patients. The dose should be given at least 30 minutes but not longer than 1 hour before the incision in clean, scheduled cases. This timing is important. Efficacy decreases with doses given earlier or later.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
