Full Title of Guideline: Guideline for the Diagnosis and Treatment of

Surgical Wound Infection in Adults

Author (include email and role): Dr Vivienne Weston - Consultant Microbiologist

Division & Speciality: Microbiology, CAS

Scope (Target audience, state if Trust
wide):
Review date (when this version goes out
of date):
Explicit definition of patient group
to which it applies (e.g. inclusion and
exclusion criteria, diagnosis):
Changes from previous version (not
applicable if this is a new guideline, enter
below if extensive):
Summary of evidence base this
guideline has been created from:
All Drs, Nurses and pharmacists. Guideline will be available on the
Clinical Effectiveness Department Intranet page and the Trust
antibiotics guidelines website
March 2021
Adult patients with surgical wound infections, excluding
obstetric caesarean and episiotomy infections- see separate
obstetric guidance.
See separate Wound Care Formulary for guidance on wound
dressings.
No major changes made. Update to references and minor wording
changes
• NICE Clinical Guideline CG74 2008 Prevention and
treatment of surgical site infection (reviewed and
renewed unchanged Jan 2017)
• The Higher Risk General Surgical Patient. Towards
Improved Care for a Forgotten Group 2011. The Royal
College of Surgeons of England and Department of
Health

This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.

Nottingham Antimicrobial Guidelines Committee Page 1 of 5

Review: March 2021
Clinical Features of Infection
Several signs and symptoms can accompany wound infection, but not all
infected wounds will exhibit all of these at any one time. Infection is
characterised by an invasion of bacteria into the tissue, whereas colonisation
is usually restricted to the wound surface. The presence of bacteria in wound
swabs therefore cannot distinguish between infection and colonisation; this
has to be correlated with the local and systemic signs of wound infection.

Acute Infections
• Abscess/pus
• Cellulitis/ excessive inflammation
o Erythema
o Oedema
o Heat
o Pain
• Unexpected pain/tenderness
• Wound dehiscence
Note the absence of a purulent discharge does not exclude an infecting
process as not all infecting organisms result in pus formation and
neutropenic patients can’t form pus .
Chronic Infections
• Wound breakdown
• Delayed healing
• Increased exudate
• Discolouration of wound bed or reformation of necrotic tissue
• Friable bleeding of granulation tissue
• Pocketing/bridging at base of wound
• Sinus formation

MANAGEMENT
Introduction
Not all surgical skin and soft tissue infections (SSIs) require antibiotic
treatment: minor infections usually respond to drainage of pus (for example,
by removal of sutures). Antibiotic therapy carries with it the risk of adverse
drug reactions and the development of resistant bacteria with the associated
risk of C. difficile diarrhoea.
Microbiological cultures (swabs and/or samples of pus/ tissue) should ideally
be sent and particularly if:-
• Clinically serious infections for urgent culture (also send blood for
culture).
• Patients are hypersensitive to first-line antibiotics.
• Antibiotic resistant pathogens are suspected, for example in recent
hospital inpatients or those returning from travel to countries with high
rates of antimicrobial-resistant pathogens. This is because the choice
of second-line antibiotics is limited in such patients, and culture results
can guide therapy should initial treatment fail. (NICE 2008).

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Incision and Drainage
Drainage of pus and debridement of any dead tissue is an important part of
the treatment, as the presence of dead (necrotic) or damaged (slough) tissue
within a surgical wound delays healing. Necrotic material or slough within the
wound margin acts as a medium for bacterial proliferation and therefore
should be removed (NICE 2008).
If the patient has high risk red sepsis, delays to source control of more than
twelve hours after onset of hypotension when compared with a delay of less
than three hours could be expected to increase mortality from 25% to more
than 60%. Rapid involvement of senior medical staff is important as control of
the source of sepsis by surgery or other means should be immediate and
underway within three hours (Royal College of Surgeons 2011).

Empirical Antibiotic Treatment

First-line antibiotic therapy (‘empirical’ or ‘blind’ therapy) should cover the
most likely infecting pathogens and take into account the patient’s clinical
status, recent antibiotic history, allergies and microbiology.
Empirical therapy should cover S. aureus, which is the most common cause
of SSI after all types of operation. If the SSI occurs after clean-contaminated
surgery that involves mucosal surfaces it should be treated with an empirical
antibiotic regimen that includes activity against anaerobic bacteria.
SSIs in patients known to have, or be at risk of methicillin-resistant S. aureus
(MRSA) carriage should be treated with an empirical antibiotic regimen that
includes activity against MRSA.
All empirical antibiotic therapy should be reviewed in the light of their clinical
progress and after culture and sensitivity results have been reported. (NICE
CG 15 2015).

Send pus / tissue and blood for culture

• Mild skin / soft tissue wound infection

Minor infections may respond to drainage of pus alone (for example, by

removal of sutures
If antibiotic treatment is required i.e. surrounding spreading cellulitis or
non-response to drainage:
o Flucloxacillin PO 500mg - 1g QDS for 5 days
OR
o Doxycycline PO 100mg BD day 1 then 100mg OD for 4 days if
allergic to penicillins or MRSA a possibility
- PLUS Metronidazole PO 400mg TDS if surgery breached the
mucosa e.g. bowel, dental, genital or respiratory tracts.

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 • Moderate wound infection without high risk red sepsis

o Flucloxacillin IV 1-2g QDS for 5-7 days (converting to

Flucloxacillin PO 1g QDS when IV to oral switch criteria met)
OR
o Vancomycin IV for 5-7 days if known MRSA (Refer to antibiotic
website for dosing, pre-dose level monitoring advice and the
vancomycin dosing calculator.)
- PLUS Metronidazole PO 400mg TDS if site includes a mucosal
site e.g. abdominal wound.

OR

o Clindamycin PO 450mg QDS (IV if NBM) if allergic to penicillins

• Severe deep wound infection or signs of high risk red sepsis

o Piperacillin / Tazobactam IV 4.5g TDS (not in penicillin allergy)

and Gentamicin IV 5 mg/kg (if normal renal function) as a single
dose (max 500mg) [See antibiotic website for dosing advice in
renal impairmentand monitoring levels]
- PLUS if prosthetic material Vancomycin IV (Refer to antibiotic
website for dosing, pre-dose level monitoring advice and the
vancomycin dosing calculator).

o Review previous microbiology. If patient has previously isolated

a multi resistant Gram negative and does not have a severe
penicillin allergy (i.e. no angioedema / anaphylaxis or immediate
onset urticarial rash): Meropenem IV 500mg QDS plus if
prosthetic material Vancomycin IV (Refer to antibiotic website
for dosing, pre-dose level monitoring advice and the vancomycin
dosing calculator)

If the patient has a severe penicillin allergy (not known ciprofloxacin

resistant Gram negative infection):
o Ciprofloxacin IV 400mg BD converting to 500-750mg BD orally
when stabilised and not NBM
- PLUS Vancomycin IV (Refer to antibiotic website for dosing,
pre-dose level monitoring advice and the vancomycin dosing
calculator)
- PLUS if surgery breached the mucosa Metronidazole IV
500mg TDS

o If the patient has a severe penicillin allergy and known to have had
Ciprofloxacin resistant Gram negative infection, the empirical choice
must be discussed with the duty/on call medical microbiologist.

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The length of treatment is determined by the site, depth and extent of the
infection and surgical / radiological drainage, the presence or absence of
prosthetic material and speed of response to treatment.

Treatment Failures
If the patient has rapidly spreading cellulitis despite empirical antibiotic
treatment, the patient should be urgently assessed to look for signs and
symptoms of necrotising fasciitis or collections. This would be an indication for
surgical exploration and removal of infected pus/ necrotic tissue. Urgent
samples to be sent to microbiology and discussion about suitable empirical
antibiotic treatment with the duty/on-call medical microbiologist.

The patient should be reviewed clinically for evidence of non-infective reasons

for wound breakdown, such as poor nutrition or other pathology such as
pyoderma gangrenosum or underlying surgical problems (for example, a
collection of pus, an anastomotic leak or a foreign body).
The results of samples sent for microbiology should be reviewed as soon as
they are available and treatment rationalised if appropriate.

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