A 52-year-old man underwent elective open cholecystectomy 5 days ago. On postoperative day 5, he develops fever (38.5°C), erythema, warmth, and purulent discharge from the surgical incision. Wound culture is pending. What is the most appropriate immediate next step in management?
A. Perform urgent incision and drainage of the wound, send pus for culture and sensitivity, and start empirical antibiotics
B. Start empirical broad-spectrum antibiotics (ceftriaxone + metronidazole) and await culture results
C. Order CT abdomen to rule out intra-abdominal collection before any intervention
D. Observe for 48 hours with local wound care and antipyretics; start antibiotics only if fever persists
Explanation
Management of Established Surgical Site Infection (SSI)
Key Point
A clinically evident SSI with purulent discharge requires immediate source control (incision and drainage) combined with empirical antibiotic therapy — not observation or imaging delay.
Why Incision and Drainage is the Priority
High-YieldNEET PG
The hallmark of SSI management is early drainage of localized pus. Purulent discharge indicates abscess formation, which will not resolve with antibiotics alone. Delay in drainage increases risk of systemic sepsis, prolonged hospitalization, and poor wound healing.
Correct Management Sequence
1.
Incision and drainage — open the wound under aseptic conditions, evacuate pus, and send for culture and sensitivity
2.
Empirical antibiotics — start immediately (do not wait for culture results) covering skin flora and gram-negatives:
First-line: Ceftriaxone 1 g IV 12-hourly + Metronidazole 400 mg IV 8-hourly (or Cefoxitin 2 g IV 6-hourly as single agent)
Adjust based on culture and sensitivity
3.
Wound management — leave wound open or loosely packed; daily dressing changes
4.
Serial examination — assess for spreading cellulitis, systemic toxicity, or deeper infection
Clinical Pearl
Early (POD 1–5) SSIs are typically caused by Staphylococcus aureus or Streptococcus pyogenes (β-hemolytic); late SSIs (POD > 5) may involve gram-negatives or anaerobes. Empirical coverage should address both.
When to Image (CT Abdomen)
Indicated if: Signs of peritonitis, sepsis unresponsive to drainage + antibiotics, or suspicion of deeper organ involvement
Not first-line in straightforward superficial/incisional SSI
Mnemonic: DRAIN-CULTURE-ANTIBIOTICS — the triad of SSI management.
Sabiston Textbook of Surgery Ch 12
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