A 58-year-old man undergoes elective open cholecystectomy for symptomatic gallstones. The procedure is uncomplicated and lasts 45 minutes. On postoperative day 4, he develops fever (38.5°C), localized erythema, warmth, and purulent drainage from the surgical incision. Wound culture grows Staphylococcus aureus. Which of the following is the most appropriate immediate management?

Explanation

## Management of Surgical Site Infection (SSI) — Superficial Incisional ### Clinical Presentation This patient presents with classic signs of superficial incisional SSI on postoperative day 4: - Fever within 30 days of surgery - Localized erythema, warmth, and purulent drainage - Positive wound culture (S. aureus) **Key Point:** Superficial incisional SSI is defined as infection occurring within 30 days of surgery, involving only skin and subcutaneous tissue, with purulent drainage and/or positive culture. ### Immediate Management Algorithm ```mermaid flowchart TD A[Suspected SSI with purulent drainage]:::outcome --> B{Deep space involvement?}:::decision B -->|No signs| C[Superficial SSI]:::outcome B -->|Fever + peritonitis + imaging findings| D[Deep/organ-space SSI]:::urgent C --> E[Open incision at bedside]:::action C --> F[Obtain wound culture before antibiotics]:::action E --> G[Drain purulent material]:::action F --> H[Start empiric antibiotics after culture]:::action G --> I[Wound care and dressing changes]:::action D --> J[Urgent imaging + surgical exploration]:::urgent ``` ### Rationale for Correct Answer **High-Yield:** The standard of care for superficial incisional SSI with purulent drainage is: 1. **Incision opening** — break down the wound to allow drainage and prevent abscess formation 2. **Culture before antibiotics** — obtain wound culture to guide targeted therapy and identify resistance patterns 3. **Empiric broad-spectrum coverage** — start antibiotics after culture (typically covering S. aureus and gram-negatives) 4. **Wound care** — regular dressing changes, saline irrigation, and healing by secondary intention **Clinical Pearl:** Opening the incision at the bedside is safe for superficial infections and prevents progression to deeper involvement. Delaying drainage risks abscess formation and systemic toxicity. ### Why NOT the Other Options | Option | Why Incorrect | |--------|---------------| | IV cefazolin + observe | Cefazolin alone is inadequate for established S. aureus SSI; observation without drainage allows pus accumulation and worsening infection | | CT before intervention | Imaging is unnecessary for superficial SSI with obvious purulent drainage; delays definitive treatment (drainage) | | Topical antibiotics + cover | Topical therapy is insufficient for systemic infection with fever; purulent material must be drained | **Warning:** Do NOT delay drainage while awaiting imaging in superficial SSI. The diagnosis is clinical; drainage is therapeutic and diagnostic. [cite:Sabiston Textbook of Surgery Ch 12]