Superficial Surgical Site Abscess
A 25-year-old man returns on the eighth day after open appendectomy for perforated appendicitis with pain and redness around the wound. The incision is discharging pus and is tender, but the abdomen is soft. Temperature is 38 °C, heart rate 110 beats/min, blood pressure 110/70 mm Hg. Which of the following is the most appropriate management?
- A.Computed tomography of the abdomen and pelvis
- B.Exploratory laparotomy for intra-abdominal sepsis
- C.Bedside opening and drainage of the woundCorrect
- D.Intravenous antibiotics alone with observation
Explanation
Purulent discharge from an incision with surrounding erythema, tenderness, fever, and tachycardia on the eighth postoperative day is a textbook superficial incisional surgical site infection, and the peak incidence of such infections is between days five and ten. Crucially, the abdomen is soft, which localises the process to the wound and argues against a deep intra-abdominal complication. The governing principle for any abscess is drainage, because pus is walled off from the circulation and antibiotics cannot achieve bactericidal concentrations inside a collection. Removing a few sutures or staples over the fluctuant area at the bedside releases the pus, and the cavity is then irrigated, packed lightly, and allowed to heal by secondary intention. Antibiotics are appropriate adjuncts here given the fever and tachycardia and the surrounding cellulitis, but they are supportive and never a substitute for drainage. Wound swabs from the drained cavity guide therapy, and after a perforated appendix the flora is typically mixed enteric aerobes and anaerobes. Cross-sectional imaging is reserved for suspected deep collections, which the soft abdomen makes unlikely. Laparotomy would be a major and unnecessary intervention for an infection confined to the incision.
Why each option
- A.
- Imaging is aimed at deep intra-abdominal collections, and a soft abdomen with an obviously infected incision makes it unnecessary.
- B.
- Laparotomy is far too aggressive for an infection localised to the incision in a patient without peritonism.
- C.
- Correct. Opening the wound at the bedside drains the pus and achieves the source control that defines abscess treatment.
- D.
- Antibiotics do not penetrate a walled-off collection and will not cure an established wound abscess on their own.
Reference: Schwartz's Principles of Surgery, 11th ed., 2019, Surgical Infections; CDC Guideline for the Prevention of Surgical Site Infection, 2017
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