Wound Care Differential Diagnosis: Postoperative Infections and Mimicking Conditions

Postoperative wound infections represent a significant challenge in surgical care, arising from a complex interplay of factors. As a common surgical complication, these infections necessitate diligent clinical attention for early identification and effective management of modifiable risk factors throughout the perioperative period. A comprehensive preoperative assessment is paramount, requiring seamless collaboration among nursing, anesthesia, and surgical teams to meticulously identify and manage patient-specific risk factors, facilitating informed patient counseling. Intraoperatively, maintaining a sterile operating room environment is non-negotiable, directly impacting patient recovery trajectories and postoperative infection rates.

While incisional infections often present with overt signs, systemic symptoms following surgery can be ambiguous, potentially mirroring conditions unrelated to surgical site infections (SSIs). These mimicking conditions, such as cellulitis, allergic reactions, urinary tract infections, and pneumonia, necessitate a robust differential diagnosis approach. Susceptibility to infection is influenced by a multitude of factors, and while diagnosis hinges primarily on clinical evaluation, wound cultures and imaging modalities may be indispensable in certain scenarios. This article provides an in-depth exploration of postoperative wound infections, encompassing etiology, epidemiology, pathophysiology, clinical presentations, evaluation strategies, and treatment modalities. Furthermore, it underscores the pivotal role of an interprofessional healthcare team and collaborative synergy between surgical and non-surgical clinicians in optimizing patient outcomes.

Objectives:

• Recognize risk factors for postoperative wound infections during preoperative evaluations.
• Implement evidence-based preventive strategies to minimize postoperative wound infection risks.
• Apply appropriate wound care techniques for the prevention and effective management of postoperative wound infections.
• Foster collaboration within interprofessional healthcare teams to ensure coordinated follow-up care and interventions, thereby enhancing patient outcomes and preventing postoperative wound infections.

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Introduction

Surgical site infections (SSIs) are a leading cause of nosocomial infections in surgical patients.[1] Historically, before the germ theory revolutionized medical practice and antisepsis became standard, postoperative surgical infection rates were alarmingly high, frequently leading to severe consequences such as limb amputation or death. The advent of antiseptic techniques marked a turning point, dramatically improving patient outcomes.[2][3][4][5][6][7]

SSIs significantly contribute to postoperative morbidity and mortality. Current data indicates their responsibility for over 2 million nosocomial infections annually in the United States.[8][9][10][11] The Centers for Disease Control and Prevention (CDC) categorizes SSIs into superficial incisional, deep incisional, and organ/space infections. A surgical wound is classified as an SSI if deemed infected by the surgeon or intentionally opened due to suspected infection, occurring within 30 days post-surgery or within 1 year for procedures involving implants. For detailed SSI category definitions, refer to the CDC-National Healthcare Safety Network (NHSN) Patient Safety Component Manual, updated January 2023.

Superficial Incisional Infections

Superficial incisional SSIs are confined to the skin and subcutaneous tissues, representing over half of all SSIs. Diagnosis requires meeting at least one of the following criteria:

• Purulent drainage from the incision site.
• Isolation of a pathogenic organism from wound fluid or tissue.
• Surgeon’s clinical diagnosis of superficial incisional SSI.
• Intentional wound opening by the surgeon with at least one sign of infection (e.g., localized pain, warmth, erythema, swelling).

Deep Incisional Infections

Deep incisional SSIs involve deeper soft tissues, including muscle and fascial layers. Diagnosis requires at least one of these criteria:

• Purulent drainage from the deep incision, but not organ/space.
• Spontaneous wound dehiscence or surgical wound dehiscence opened intentionally by a surgeon when at least one of the following signs or symptoms is present: fever (>38°C), localized pain, or tenderness.
• A deep incision that is deliberately reopened by a surgeon and is culture-positive for microorganism(s).
• Evidence of deep soft tissue abscess or infection upon direct examination, during reoperation, or by histopathologic or radiologic study.

Organ/Space Infections

Organ/space SSIs affect any organ or space manipulated during surgery, excluding the incision site itself, and extend beyond the fascial/muscle layers. This includes implant-related infections. Diagnosis requires at least one of the following:

• Purulent drainage from a drain placed into the organ/space.
• Isolation of microorganisms from an aseptically obtained culture of fluid or tissue in the organ/space.
• Evidence of an abscess or infection involving the organ/space, identified via direct examination, during reoperation, or by histopathologic or radiologic study.

It is crucial to distinguish SSIs from conditions such as stitch abscesses, localized cellulitis, or infected superficial stab punctures, which are not classified as SSIs.

The majority of SSIs originate from endogenous flora, typically residing on mucous membranes, skin, or within hollow viscera. The risk of wound infection escalates significantly when microbial concentration exceeds 100,000 microorganisms per gram of tissue.[12]

Etiology

Postoperative wound infections arise from a multitude of sources, including direct contact, airborne transmission, and contamination by endogenous microbes. Patient susceptibility is modulated by a diverse array of factors. Infection patterns exhibit variability depending on the surgical procedure, operative approach, and geographical context. Risk factors are broadly categorized into patient-related and procedure-related factors.

Patient-related risk factors for wound infection encompass advanced age, malnutrition, hypovolemia, obesity, steroid use, poorly controlled diabetes mellitus, immunocompromised states, smoking, pre-existing trauma, surgical site location (intra-abdominal, pelvic, or extremity), prolonged preoperative hospitalization, inadequate preoperative skin hygiene, and distant site infections.

Optimizing modifiable patient factors prior to elective surgery is crucial. These include smoking cessation, weight management, coagulation profile normalization, glycemic control optimization, and stabilization of pre-existing comorbidities.

Procedure-related risk factors include:

• Abnormal fluid collections (hematoma, seroma)
• Surgical site, equipment, or personnel contamination
• Drain utilization
• Foreign material presence at the surgical site
• Hypothermia
• Improper hair removal techniques
• Inadequate antibiotic prophylaxis
• Insufficient skin preparation
• Inadequate preoperative surgical scrub duration
• Prolonged surgical duration
• Suboptimal operating room (OR) ventilation
• History of prior infection or contaminated surgical case
• Extended perioperative inpatient stay
• Unsatisfactory surgical practices and techniques, including:
  • Failure to maintain tissue hydration through periodic saline irrigation
  • Direct organ or tissue trauma
  • Excessive tension during tissue traction or closure
  • Excessive tissue trauma
  • Failure to remove devitalized or necrotic tissue
  • Inadequate hemostasis
  • Leaving excessive dead space
  • Overuse of electrocautery
  • Tissue devascularization
  • Unintended bowel content spillage
  • Unnecessary or prolonged drain usage [13][14][15][16]

Adherence to preoperative and operative checklists is vital for minimizing SSI rates. The OR team shares collective responsibility for implementing best practices. Optimal OR ventilation, achieved through positive pressurization with adequate HEPA filtration, airflow, and air exchange (ideally ≥15 exchanges/hour), is paramount. Air intake should be HEPA-filtered and sourced externally, entering via ceiling or high-wall inlets, with exhausts located near floor level.[17][18]

Preoperative chlorhexidine showers, recommended the night before and/or day of surgery, aim to reduce patient skin flora. Hair removal, when necessary, should be performed immediately preoperatively using clippers (avoiding razors due to increased skin trauma risk). Clippers are generally not recommended before scrotal surgery due to potential skin trauma. Chlorhexidine and alcohol-based agents are generally favored for skin preparation in most surgical specialties.

Regular cleaning of tools and accessories (stethoscopes, blood pressure cuffs, patient transfer slides, tourniquets, computer keyboards) is crucial to prevent bacterial contamination.[19][20][21][22][23] Surgical devices (anesthesia/cautery units, suction machines, OR lighting, patient transfer aids) can also serve as contamination sources. Storage of towels, sheets, and similar materials should be within closed cabinets or outside the OR. Proper surgical scrubbing techniques and double gloving reduce postoperative infection incidence.[24] The World Health Organization (WHO) surgical safety checklist promotes communication, complication prevention, and improved safety and outcomes, including SSI prevention. Surgical procedures are classified as clean, clean-contaminated, contaminated, and dirty-infected, each associated with varying postoperative wound infection risks.

The Canadian Agency for Drugs and Technologies in Health (CADTH) Report 2011 classification defines these categories:

• Clean: Procedures performed in the absence of inflammation, maintaining sterility without entering the gastrointestinal, urogenital, or pulmonary tracts.

• Clean-contaminated: Procedures involving controlled entry into the gastrointestinal, urogenital, or pulmonary tracts without significant spillage or pre-existing infection.

• Contaminated: Procedures involving a major break in sterile technique, gross spillage from the gastrointestinal tract, or incisions through acutely inflamed (non-purulent) tissue. This includes open traumatic wounds >12 to 24 hours old.

Epidemiology

Approximately 0.5% to 3% of surgical patients develop an SSI.[26] The increasing prevalence of outpatient surgery complicates postoperative data collection. The NHSN has initiated protocols to collect SSI data from ambulatory surgical centers. SSIs often manifest post-discharge or after ambulatory center visits, documented in outpatient notes potentially not integrated into hospital records. CDC/NHSN data should be interpreted within this context.

Despite enhanced preventive measures leading to a reduction in SSI incidence over time, SSIs remain a significant contributor to morbidity and mortality. They account for approximately 20% of healthcare-associated infections.[27][28] SSI patients have higher ICU admission rates and a 2 to 11 times greater mortality risk. They are also 5 times more likely to experience hospital readmission, with SSIs being the most common cause of unplanned postoperative readmissions.[29][30][31][1][32]

In 2018, the US reported 157,500 SSIs with an estimated 8205 deaths. 11% of ICU deaths were linked to SSIs. SSI patients require an average of 10-11 additional hospital days, incurring extra costs exceeding $20,000 per admission, resulting in an estimated $3.3 billion annual financial burden on the US healthcare system.[27][33]

SSI rates correlate with surgical wound contamination at the time of surgery (see Table).[34][35]

Table

Table. Surgical Site Infection Rates by Degree of Contamination.

Pathophysiology

SSI development typically begins with microbial wound contamination. Virulence and quantity of contaminating organisms are key factors, with infection often defined as >10⁵ microorganisms per gram of tissue without a foreign body. Etiologic agents can be endogenous or exogenous. Endogenous microbes originate from the patient’s skin, mucous membranes, hollow viscera, or hematogenous spread. Common endogenous SSI pathogens vary by surgical site. Staphylococcus aureus and coagulase-negative staphylococci are frequent isolates in cardiac, breast, ophthalmic, orthopedic, and vascular surgeries. Enterococcus, gram-negative bacilli, and anaerobes are more common in abdominopelvic procedures.[36]

Exogenous microbes originate from the OR environment or personnel, transmitted via air, instruments, materials, or staff. Staphylococci and streptococci are common exogenous SSI organisms. However, highly virulent hospital-acquired organisms like methicillin-resistant S. aureus (MRSA) and extended-spectrum β-lactamase-producing microbes are increasingly isolated in SSIs, likely due to broad-spectrum antibiotic overuse. For example, a study in southeastern US community hospitals showed MRSA-associated SSI incidence increased from 12% in 2000 to 23% in 2005. The 2010 NHSN update reported 43.7% of SSIs attributed to MRSA.[12]

History and Physical Examination

SSI symptoms typically manifest 3-7 days post-procedure, but by definition, must occur within 30 or 90 days, depending on the surgical procedure type.[37]

Procedures with a 90-day SSI surveillance period include breast surgery, cardiac surgery, coronary artery bypass graft (CABG) with chest and donor site incisions, CABG with chest incision only, craniotomy, spinal fusion, open fracture reduction, herniorrhaphy, hip prosthesis, knee prosthesis, pacemaker surgery, peripheral vascular bypass surgery, and ventricular shunt placement.

Technically demanding, prolonged, contaminated, or emergent surgeries of any type increase SSI risk. Superficial or deep incisional SSI patients often present with gradual onset of surgical site pain and malaise or fatigue. They may report incisional drainage or frequently saturated dressings. Organ/space SSI patients may describe localized or generalized pain and systemic symptoms like fever, chills, night sweats, fatigue, or malaise. Physical examination may reveal incisional erythema, purulent or non-purulent discharge, wound dehiscence, or delayed healing. Tenderness to palpation may be localized or diffuse.

In-person physical examination is preferred for suspected SSIs. If impossible, visualization of the affected area is crucial. Wound photography in telemedicine has improved diagnostic accuracy and reduced overtreatment in situations where face-to-face meetings are not feasible.[38]

Dressings must be removed for examination, and the wound inspected for blisters, wound tension, edema, disproportionate tenderness, excessive erythema, fluctuance, blackish-gray tissue, and signs of ischemia or necrosis. Palpation should be performed using sterile technique. Intentional or secondary wound openings should be probed with a sterile cotton swab to assess dead space, deep closure integrity, fluid pockets, and tissue undermining. Any discharge, purulent or not, should be sampled for culture, sensitivity, and microbiological analysis.

Evaluation

SSI diagnosis is primarily clinical. However, wound cultures are essential to identify potential pathogens and guide antibiotic therapy. Imaging (ultrasound, CT, MRI) is helpful for suspected deep space infections. Risk prediction tools exist, including the National Nosocomial Infection Surveillance System, Australian Clinical Risk Index, and European System for Cardiac Operative Risk Evaluation. However, their clinical value is limited by the exclusion of many risk factors, weak discriminatory ability, or lack of surgery-specific risk stratification. Specialty- and operation-specific scoring systems are emerging, such as the Infection Risk Index in Cardiac Surgery and the Surgical Site Infection Risk Score.[39][40][41][42]

Superficial incisional SSI patients typically lack systemic infection signs, though fever and leukocytosis may be present. Imaging is generally not recommended. Deep incisional SSI patients are more likely to have systemic signs like fever. Laboratory evaluation may show leukocytosis with a left shift and elevated procalcitonin and C-reactive protein, though these are not essential for diagnosis. While superficial incisional SSI diagnosis is usually straightforward, deep incisional SSI diagnosis can be challenging clinically, especially in obese patients. Ultrasound or CT can help assess depth, extent, and anatomical involvement. Image-guided aspiration and drainage with culture can guide antibiotic therapy and improve outcomes.

Organ/space SSI patients typically present with systemic signs and symptoms of inflammation and infection, even if superficial incisions appear uninfected. Organ/space SSI diagnosis almost always requires imaging, often revealing fluid collections or abscesses near the surgical site. Image-guided aspiration is clinically useful, and interventional radiology consultation for drain placement is recommended when available.

Necrotizing soft tissue infections (NSTIs) are a distinct, life-threatening SSI subset with high morbidity and mortality. Patients typically become critically ill within 48-72 hours post-surgery and often exhibit sepsis signs. Physical examination usually reveals disproportionate pain, dusky or erythematous skin, peri-incisional edema, crepitus, ecchymosis, hypovascularity, blistering, or frank necrosis.[43][44][45] Excessive incisional drainage may be present. Laboratory evaluation may show leukocytosis or leukopenia. NSTIs can involve any tissue, spreading rapidly along fascial planes. Imaging can confirm diagnosis but should not delay surgical exploration and debridement in suspected cases.[46] Fournier gangrene is a postoperative NSTI example and a surgical emergency.[47]

Differential Diagnosis in Postoperative Wound Care

A crucial aspect of wound care, particularly in the postoperative setting, is the differential diagnosis. While the focus may be on surgical site infections, clinicians must consider other conditions that can mimic infection or complicate wound healing. A thorough differential diagnosis ensures appropriate and timely intervention, preventing misdiagnosis and suboptimal patient management.

Conditions to Consider in the Differential Diagnosis of Postoperative Wound Infections:

• Non-Infectious Inflammatory Conditions:

  • Surgical Site Inflammation: Normal postoperative inflammation can present with erythema, warmth, and mild tenderness. This is typically most pronounced in the first few days after surgery and gradually subsides. Differentiating this from infection relies on the absence of purulent drainage and systemic signs of infection.
  • Seroma: A collection of serous fluid in the surgical site, seromas can cause swelling, discomfort, and sometimes erythema. They are not infections but can become secondarily infected. Aspiration can differentiate seroma fluid (clear, straw-colored) from purulent drainage.
  • Hematoma: Blood collection at the surgical site can also cause swelling, bruising, and pain. Similar to seromas, hematomas are not infections but increase the risk of infection. Appearance and aspiration can aid in differentiation.
  • Drug Reactions/Allergic Dermatitis: Reactions to skin preparations, dressings, sutures, or medications can manifest as erythema, pruritus, and even blistering, mimicking superficial infections. A careful history of new exposures and the distribution of the rash can be helpful.
  • Contact Dermatitis: Irritation from dressings, soaps, or topical agents can cause localized inflammation. Removing the offending agent and observing for improvement can aid in diagnosis.
  • Gout/Pseudogout: In patients with predisposing factors, postoperative stress can trigger crystal deposition diseases, particularly in extremity wounds. Joint involvement and crystal analysis of joint fluid (if applicable) are diagnostic.

• Infectious Conditions Mimicking SSI:

  • Cellulitis: Bacterial infection of the skin and subcutaneous tissue, cellulitis can occur near a surgical site but not be directly related to the incision. It typically presents with spreading erythema, warmth, tenderness, and often lacks a defined focus like a surgical incision.
  • Erysipelas: A superficial form of cellulitis characterized by sharply demarcated, raised erythema, often caused by Streptococcus pyogenes.
  • Folliculitis/Furuncles/Carbuncles: Infections of hair follicles or deeper skin structures can occur near surgical sites and be mistaken for superficial SSIs. These often present as discrete, raised, and sometimes purulent lesions rather than diffuse wound infections.
  • Abscesses (Unrelated to Surgery): Pre-existing or newly developed abscesses in adjacent tissues can present with similar signs of inflammation. Location and context are important for differentiation.
  • Urinary Tract Infection (UTI): Postoperative UTIs are common and can cause fever and malaise, symptoms that overlap with SSIs, especially organ/space infections if the surgery involved the urinary tract. Urinalysis is essential to rule out UTI.
  • Pneumonia: Postoperative pneumonia is another common complication that can cause fever, chills, and malaise, mimicking systemic signs of infection. Respiratory symptoms and chest X-ray are key for diagnosis.
  • Pulmonary Embolism (PE): While not an infection, PE can cause fever, tachycardia, and general malaise, sometimes mimicking sepsis from a severe SSI. Risk factors for PE and respiratory/cardiovascular assessments are important.
  • Deep Vein Thrombosis (DVT): DVT can cause localized pain, swelling, and warmth in an extremity, potentially near a surgical site, mimicking cellulitis or deep SSI. Doppler ultrasound is used for diagnosis.
  • Meningitis/Encephalitis: In neurosurgical patients, postoperative fever and altered mental status could be due to CNS infections, requiring differentiation from SSIs. Neurological exam and CSF analysis are crucial.
  • Endocarditis: In patients with cardiac risk factors or procedures, endocarditis should be considered in the differential for postoperative fever, particularly if blood cultures are positive but wound cultures are negative or discordant.

Diagnostic Approach to Differential Diagnosis:

1. Thorough History and Physical Examination: Detailed history including timing of symptom onset, nature of pain, presence of drainage, systemic symptoms, and relevant past medical history. Comprehensive physical exam focusing on the wound characteristics (drainage, erythema, warmth, tenderness, wound edges, depth), and assessment for systemic signs (fever, tachycardia, hypotension).
2. Wound Assessment: Careful inspection of the wound, noting the type of drainage (purulent, serous, serosanguineous), color, odor, and extent of surrounding erythema and induration. Palpation to assess for fluctuance, warmth, and tenderness.
3. Wound Culture: Collect wound cultures, particularly if drainage is present, to identify causative organisms and guide antibiotic therapy if infection is suspected.
4. Laboratory Investigations:
   • Complete Blood Count (CBC): Leukocytosis with neutrophilia may suggest infection, but can also be elevated due to non-infectious inflammation.
   • C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Elevated inflammatory markers, but non-specific and can be elevated in both infectious and non-infectious conditions.
   • Urinalysis: To rule out UTI, particularly if urinary symptoms are present or the surgery involved the urinary tract.
   • Blood Cultures: Consider if systemic signs of infection are present, especially in suspected sepsis or organ/space infections.
5. Imaging Studies:
   • Ultrasound: Useful for identifying fluid collections (seroma, hematoma, abscess) and guiding aspiration.
   • CT Scan/MRI: For deeper infections or organ/space infections, to delineate the extent of infection and identify abscesses. Also helpful in ruling out other intra-abdominal or thoracic conditions.
   • Chest X-ray: To rule out pneumonia, especially if respiratory symptoms are present.
   • Doppler Ultrasound: To rule out DVT if extremity swelling or pain is present.
6. Aspiration and Fluid Analysis: Aspirate fluid collections (seroma, hematoma, suspected abscesses) for Gram stain, culture, and cell count to differentiate infectious from non-infectious collections.
7. Clinical Course and Response to Treatment: Monitor the patient’s clinical course and response to interventions. Lack of improvement with antibiotics may suggest a non-infectious etiology or antibiotic resistance. Conversely, resolution with wound care and/or antibiotics supports the diagnosis of SSI.

A systematic approach to differential diagnosis, incorporating clinical assessment, laboratory and imaging investigations, and consideration of alternative diagnoses, is essential for effective postoperative wound care and preventing misdiagnosis of surgical site infections.

Treatment / Management

Preventive Measures

Preventive measures are paramount to minimize postoperative infections. A checklist-based approach and meticulous attention to known risk factors are crucial. The “CDC and Health Infection Control Practice Advisory Committee Guideline for the Prevention of Surgical Site Infections” (2017) provides comprehensive, evidence-based recommendations. Preventive measures are categorized into pre-procedural, perioperative, and intraoperative phases. Pre-procedural considerations include optimizing chronic health conditions (glucose control), medication review, addressing chronic wounds/infections, and smoking cessation. Perioperative steps encompass preoperative showers, hair clipping, operation-specific antibiotic administration, and appropriate skin preparation. Maintaining optimal intraoperative conditions (temperature, air circulation, sterility) is vital for preventing wound infections.[29][48]

A large Japanese study demonstrated significant SSI reduction through perioperative oral hygiene regimens, including tartar/plaque/scale removal, professional dental cleaning, optimal denture care/adjustments, and high-quality general dental care (extractions as needed preoperatively).[49] A large trial showed that changing surgical gloves and instruments immediately before abdominal wound closure resulted in a statistically significant SSI rate reduction. While preliminary, these findings warrant further research to validate this approach.[50]

Routine surgical drain use is discouraged due to uncertain efficacy in SSI prevention and potential impedance of early patient mobilization.[51][52][53] If used, drains should be promptly removed. Various measures (antibiotic irrigation, topical antimicrobial gels, antibiotic-impregnated sutures, antiseptic dressings) have been explored to reduce SSI incidence, but definitive evidence of significant efficacy is currently lacking.

Delayed primary closure, historically used for significantly contaminated wounds, aimed to reduce SSIs in specific populations. However, a meta-analysis of randomized studies showed no significant clinical benefit with this practice.[54][55] Antibiotic selection, tailored to the surgical procedure and prevalent microbes, remains crucial for SSI prevention.

Prophylactic negative pressure wound therapy (NPWT) for closed surgical incisions has been proposed for high-risk and contaminated wounds.[56][57] Data generally support NPWT in high-risk surgeries, but outcomes vary, likely due to differences in wound contamination levels and patient/wound characteristics.[58][59] Evidence does not suggest that surgical dressing selection for closed incisions significantly impacts SSI incidence.[60] However, prophylactic wound protectors for laparoscopy, laparotomy, and orthopedic incisions appear beneficial.[61][62][63][64][65][66]

Treatment of Surgical Site Infections

Treatment decisions depend on the procedure, microbes involved, anatomical considerations, and patient characteristics. Foreign body presence (mesh, implants, stents, metalwork) may necessitate removal due to contamination and biofilm formation.[67] Cultures are indicated for open wounds and drainage, especially purulent, to guide antibiotic selection. Negative wound cultures may suggest unusual infections (acid-fast bacteria, fungi), particularly in immunocompromised patients, requiring specific cultures.

Systemic antibiotics are needed for systemic infection signs (fever, significant erythema, cellulitis) or deeper soft tissue involvement. Blood cultures should be considered in patients with systemic infection signs. Timely interventions in sepsis are life-saving. Superficial infections may be treated with local wound care.[68] Superficial wound infection treatment involves incision opening, wound examination, infected fluid drainage, and necrotic tissue debridement, typically at the bedside or in the office. Deeper involvement may require drainage via interventional radiology or in the OR.

Opened wounds require dressings to create a clean, moisture-balanced environment, with appropriate debridement and temperature maintenance to promote healing.[69] A balanced wound matrix prevents desiccation-induced necrosis and contains growth factors supporting healing, epithelial regeneration, and autolysis of dead tissue. Wound dressings are tailored to specific wound environments. Dressing choice and change frequency depend on wound condition and healing stage. Topical antiseptics (hydrogen peroxide, dilute sodium hypochlorite, povidone-iodine) may be sparingly used in infected open wounds, but application should be limited due to cytotoxicity to the wound matrix.

Enzymatic agents are used when mechanical debridement is not feasible.[70] Cleaning and debridement should be repeated until necrotic/devitalized tissue is absent and healthy granulation tissue forms. Infected foreign material/implants should be removed.

Vacuum-assisted wound therapy (NPWT) uses negative pressure to minimize dressing changes, avoid fluid accumulation, and promote granulation. NPWT is used for major trauma, orthopedic procedures, burn surgeries, and open abdominal wounds.[71] Meta-analyses show statistically significant SSI reduction after spinal surgery, fewer postoperative complications, and shorter hospital stays with NPWT.[[72]](#article-31404.r72] Similar positive outcomes with NPWT (VAC) have been reported for SSIs after cesarean sections.[73]

NPWT-managed wounds may require intermittent mechanical debridement. NPWT requires specialized oversight, especially with exposed underlying organs or major blood vessels. Deep abdominal SSIs pose unique challenges due to dehiscence risk. Exploration may be safer in the OR. Percutaneous drainage may be considered for infected fluid collections. Organ/space SSIs have higher morbidity and mortality. Ultrasound/CT-guided percutaneous drain placement into infected fluid collections/abscesses, potentially related to anastomotic leaks after bowel surgery, is helpful. Air or contrast in an intra-abdominal abscess suggests bowel perforation or anastomotic leak.

Special Situations

Mesh-related infections (hernias) typically require drainage (percutaneous possible), antibiotics, wound debridement, and potential mesh removal. If no improvement in 10-14 days, more aggressive intervention (OR exploration, mesh removal) may be needed. While some reports describe successful treatment with systemic and locally injected antibiotics, this is not standard care and generally not recommended.[74][75][76]

Orthopedic hardware infection management may include bone debridement, antibiotic wound therapy, long-term antibiotics, implant/cement removal, wound irrigation, and/or surgical debridement.[77] Select patients may be treated with debridement and antibiotics without hardware removal, but failure likely requires resection arthroplasty.[78][79] Antibiotic-impregnated cement/polymer-coated intramedullary nails show promise in preliminary studies.[80] Infected vascular grafts generally require affected section removal and alternative vascular augmentation using uninfected tissue.[81][82] Compromised overlying skin may need excision.[83] Partial graft excision may be reasonable in selected patients, but meta-analyses show high recurrent infection risk and reoperation necessity.[84]

Absorbable meshes, providing structural matrix and releasing healing/tissue growth factors, are promising adjunct treatments for impaired wound healing, especially in diabetic patients.[85] Hyperbaric oxygen therapy may be used for complex, non-healing postoperative wounds, with reported ~75% success rates. See StatPearls’ “Hyperbaric Therapy for Wound Healing” for more information.”[86]

Prognosis

Early recognition and prompt treatment of surgical wounds are crucial for optimal prognosis. Prevention protocol adherence is the most prudent approach. Various models aid in identifying high-risk patients and preventing SSIs. For example, a colorectal cancer study identified physiological factors, tumor characteristics, and surgery type as SSI predictors.[87] Surgical factors (procedure type, emergency surgery, wound class, drains, surgeon experience, prolonged OR time) and postoperative factors (extended hospital stay, intraoperative transfusions) are independent SSI risk factors.[88]

Complications

SSI complications can be local or systemic. Local complications include delayed wound healing, chronic wounds, local tissue damage, superimposed infections, abscess formation, and osteomyelitis. Systemic complications include bacteremia, hematogenous spread, sepsis, organ failure, and exacerbation of comorbidities.

Postoperative and Rehabilitation Care

Postoperative wound care is central to postoperative hospital/rehabilitation stays, as the wound may be the primary reason for in-house care. Effective wound care and healing are essential for patient well-being and survival. Wound care is an evolving, sophisticated specialty. Adequate postoperative wound care requires timely evaluation and deliberate interventions for optimal patient outcomes.

Consultations

Postoperative wound infection management may require expertise from infectious disease, plastic surgery, and critical care specialists.

Deterrence and Patient Education

Modifiable patient risk factors (BMI, diabetic control, smoking status) can minimize postoperative wound infections. Elective surgeries involve preoperative education and counseling. Patients may be encouraged to lose weight, adhere to medication regimens, and adopt healthy habits preoperatively. Smoking cessation is crucial. Family involvement in these discussions is beneficial. Recommendations and protocols vary based on preexisting conditions and planned surgery. Spinal surgery protocols may suggest HbA1c <8%, α-blockers for males ≥60, serum albumin >3.5 g/dL, cardiac stress tests, and smoking cessation.[89]

Pearls and Other Issues

Antiseptic Preoperative Prep Solutions

Iodine-based sterilizing solutions (povidone-iodine) release free iodine, disrupting bacterial DNA and essential intracellular proteins. They are broad-spectrum, accessible, cost-effective, and safe for all skin surfaces, especially beneficial for transvaginal/transurethral prep due to mucosal surface safety. Caution is needed in iodine allergy, and these solutions should be avoided in such patients. Typically, skin is scrubbed and then painted with iodine solution.

Alcohol-based prep solutions are broad-spectrum, inexpensive, fast, and quick-acting. Single application is usually sufficient, and they dry rapidly. Compared to iodine-based solutions, they are easier to apply, have longer-lasting antimicrobial effect, greater efficacy, shorter drying times, and are more cost-effective. However, they are flammable, requiring complete skin drying before proceeding, and are unsuitable for mucous membranes.[1]

Chlorhexidine gluconate (aqueous solution) disrupts bacterial cell membranes, offering longer antiseptic activity than iodine-based antiseptics and is more resistant to neutralization. Chlorhexidine is common for preoperative showering, surgeon hand-scrubbing, and skin prep. A large study comparing chlorhexidine to iodine-based skin prep showed no significant SSI rate difference.[90]

Alcohol-based solutions with iodine or chlorhexidine combine benefits, generally providing longer-duration antisepsis than single agents. Combining agents with different antimicrobial modes appears to provide additive efficacy compared to single agents.[91]

Surgical prophylaxis antibiotic selection should be safe, narrow-spectrum, and cover expected microorganisms. Administer antibiotics 30-60 minutes before incision/instrumentation to ensure therapeutic levels by surgery start.

• Clean procedures: Antibiotics should cover skin flora, primarily staphylococci.
• Clean-contaminated procedures: Coverage should extend to gram-negative rods and enterococci, alongside staphylococci, depending on procedure. Common choices: cefazolin 2 g (weight-adjusted) or vancomycin 15 mg/kg + metronidazole, cefoxitin, or ertapenem.
• Contaminated and dirty procedures: Continue pre-established antibiotic regimen or adjust intraoperatively based on findings.*

*Note: Infectious disease and pharmacy professionals should be involved to optimize treatment based on perioperative culture results.

Enhancing Healthcare Team Outcomes

Perioperatively, patients interact with numerous healthcare professionals involved in mitigating SSI risk. Preoperatively, identify and address modifiable risk factors and provide patient counseling on potential risks. While risk discussions are primarily by nursing staff, anesthesiologists, and surgeons, all interprofessional team members must educate patients and reinforce preventive measures.

Maintaining OR cleanliness, especially around the operating table, is essential. Items like anesthesia units, personal staff belongings, and medical equipment should be considered contaminated and cleaned regularly. Intraoperatively, OR personnel must maintain sterility and optimize the surgical environment. Postoperatively, all involved clinicians influence recovery and SSI rates.[92]

Review Questions

Link to Review Questions

References

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