## 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-Yield:** 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. [cite:Sabiston Textbook of Surgery Ch 12]
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