Wound Infection - Treatment

Tactics of managing patients with wound infection. There are different views on managing patients with wound infection. The differences mainly concern the degree of surgical intervention in the wound process.

Principles of active surgical treatment of purulent wounds:

• surgical treatment of a wound or purulent focus;
• drainage of the wound using a perforated polyvinyl chloride drainage and prolonged washing with antiseptics;
• the earliest possible closure of the wound using primary, primary delayed, early secondary sutures or skin grafting;
• general and local antibacterial therapy;
• increasing the specific and non-specific reactivity of the body.

Conservative treatment, including targeted antibacterial therapy, the use of immunomodulators and drugs that improve tissue trophism, is carried out in parallel with the main treatment.

Surgical treatment of the wound. Primary purulent wounds are wounds formed after operations for acute purulent processes (opening of abscesses, phlegmons), as well as after the edges of the postoperative wound are spread apart due to suppuration. These may be wounds on the anterior abdominal wall, perineum.

Surgical treatment of the wound with resection of necrotic tissue prevents eventration and the formation of extensive aponeurosis defects.

Principles of treating a purulent wound:

• adequate pain relief;
• strict observance of asepsis;
• wide opening of the wound and revision of pockets and leaks not only in the subcutaneous fat, but also in the subaponeurotic space;
• removal of pus, hematomas, ligatures, wound sanitation with antiseptic solutions;
• removal of all non-viable purulent-necrotic tissues - tissues with purulent melting (macro- and microabscesses); necrotic tissues (areas of "black" color) must be removed;
• the appearance of bleeding during the treatment (necrotic tissue is not supplied with blood) serves as a reliable indicator of the correct determination of the tissue viability limit;
• performing careful hemostasis;
• change of tools, linen;
• re-sanitation of the wound;
• layer-by-layer suturing of the wound with infrequent individual sutures;
• the fundamental position is the rejection of all types of passive drainage in case of wound infection (turundas, rubber bands, tubes, "bundles" of tubes, tampons); at the beginning of the century it was experimentally proven (Petrov V.I., 1912) that after only 6 hours gauze tampons turn into plugs soaked in pus, which not only do not have any sanitizing properties, but also impede the natural outflow of exudate, the accumulation and absorption of which leads to the appearance of symptoms of purulent-resorptive fever;
• if it is impossible to perform aspiration-washing drainage (lack of equipment), it is recommended that the patient be in a natural position - on the opposite side or on the stomach, and also carry out periodic probing and spreading of the skin edges of the wound;
• "dry" management of a skin wound - treatment of the skin with a solution of brilliant green or potassium permanganate;
• mandatory wearing of a bandage;
• removal of secondary sutures on the 10th-12th day.

If it is not possible to immediately suture the wound after its surgical treatment, it is advisable to perform open wound sanitation. For this purpose, we wash the wound with antiseptic solutions, and then apply pads with enzymes (trypsin, chymotrypsin) moistened with saline solution to the wound surfaces, initially 2 times a day, then once, which promotes early rejection of purulent-necrotic tissue, enzymatic cleansing of the wound and the appearance of fresh granulations.

After the wound is cleansed (usually within 5-7 days), sutures are applied and the wound is closed, applying so-called early secondary sutures. Sutures are applied according to the previously described method, with the only difference that, as a rule, a wide revision of the wound and necrectomy are no longer required. Good anesthesia, compliance with the rules of asepsis, wound sanitation with dioxidine, application of rare sutures with careful comparison of the edges of the wound, its subsequent probing and "dry" treatment of sutures - this is what is usually required to obtain a good surgical and cosmetic result, when the wound is difficult to distinguish from one healed by primary intention.

The same applies to infected wounds on the perineum in obstetric patients or gynecological patients with complications of plastic surgery.

We remove the stitches on the 10th-12th day, often on an outpatient basis.

In the presence of large hematomas of the anterior abdominal wall, they are emptied in the operating room under general anesthesia. The edges of the skin wound are spread apart, and the sutures are removed from the aponeurosis. As a rule, it is impossible to find a bleeding vessel in immobilized tissues, and by this time it is thrombosed or mechanically compressed by the hematoma. Adequate assistance in this case is the removal of blood and clots, fragments of suture material, sanitation with a dioxidine solution and layer-by-layer suturing of the anterior abdominal wall with infrequent sutures. In case of diffuse tissue bleeding, as well as in case of hematoma suppuration, a tube for aspiration and lavage drainage is inserted into the subaponeurotic space; in other cases, traditional application of cold and weight is limited.

We do the same in cases of hematomas (suppurating hematomas) of the perineum and vagina. In the postoperative period, we carry out early activation of patients, the prescriptions are supplemented with douching (twice a day).

It is also fundamental that we refuse to passively manage patients with wound infections - discharging patients with unhealed wounds and recommending various options for palliative interventions, for example, bringing the edges of the wound together with a plaster, etc., etc., as well as dressings at the place of residence.

It is known that epithelium grows on the surface of granulations at a low rate - 1 mm along the perimeter of the wound in 7-10 days. With an elementary calculation, the diastasis between the edges of the wound of 1 cm is completely epithelialized no earlier than in 2 months.

All these months the patients are "tied" to the clinic, visiting the surgeon at least once every three days, they are limited in hygiene procedures, sometimes the patients are forced to do the dressings themselves (or with the help of relatives). And this is not to mention the reduction of the surgical (possibility of hernia formation) and cosmetic (wide deforming scars) effects of the operation and moral costs. Unlike patients with passive management of wound infection, patients with secondary sutures (if the sutures were not removed in the hospital) visit the surgeon on an outpatient basis no more than 2-3 times - to monitor the condition of the sutures and remove them.

Medicinal component of treatment of patients with wound infection.

The nature of therapy is individual and depends on the severity of the wound infection, the presence of concomitant diseases, and the phase of the wound process.

In the stage of infiltration and suppuration, antibiotics are indicated. If an antibiogram is available, treatment is carried out with antibiotics that are most sensitive to the pathogen in an energetic course (with observance of single, daily and course doses lasting 5-7 days). In the absence of bacteriological studies, empirical therapy is carried out, taking into account the clinical course of the wound infection. The most appropriate is the use of lincosamides, which have a broad spectrum of action on gram-positive and anaerobic flora.

For example: lincomycin in a single dose of 0.6 g, daily dose of 2.4 g, course dose of 12 g, clindamycin in a single dose of 0.15 g, daily dose of 0.6 g, course dose of 3 g.

In severe cases, they are prescribed in combination with aminoglycosides that have high selective sensitivity to gram-negative flora, for example, lincomycin + gentamicin or clindamycin + gentamicin (lincomycin in a single dose of 0.6 g, a daily dose of 2.4 g, a course dose of 12 g, clindamycin in a single dose of 0.3 g, a daily dose of 0.9 g, a course dose of 4.5 g, gentamicin in a single dose of 0.08 g, a daily dose of 0.24 g, a course dose of 1.2 g).

Also highly effective is the administration of fluoroquinolones, for example, ciprofloxacin 200 mg 2 times intravenously, in severe cases in combination with metrogyl 0.5 g (100 ml) 3 times a day.

In case of Pseudomonas aeruginosa infection, it is recommended to prescribe drugs with high antipseudomonas activity - third-generation cephalosporins, for example, cefotaxime (claforan) in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g, or ceftazidime (Fortum) in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g.

In milder cases, lincosamides or fluoroquinolones are prescribed orally, for example, klindafer 0.6 g 3 times a day or ciprofloxacin (Cyplox) 0.5 g 2 times in combination with trichopolum 0.5 g 2 times for 5 days.

Prevention of wound infection

The basis for the prevention of wound infection is the perioperative administration of antibiotics.

To avoid wound infection, it is necessary to strictly adhere to a number of principles during surgical intervention:

• perform careful hemostasis;
• handle fabrics carefully, causing minimal trauma to them;
• avoid excessive coagulation;
• avoid the imposition of frequent (less than 0.6 cm), constricting sutures;
• use a suction device;
• At the end of the operation, irrigate the subcutaneous tissue with an antiseptic - a solution of dioxidine.

Knowledge of the anatomy of the anterior abdominal wall helps to avoid hemostasis defects that lead to the development of hematomas. The danger of hematoma formation is represented by:

• insufficient hemostasis of the vasa epigastrica superficialis during laparotomy according to Pfannenstiel (located in the subcutaneous tissue of the corners of the wound), which can cause bleeding from the wound and the formation of subcutaneous hematomas (prevention - careful doping, if necessary with suturing of vessels);
• numerous vessels of various calibers that feed the rectus muscles are crossed during Pfannenstiel laparotomy, when the aponeurosis is separated from the rectus muscles of the abdomen, and subaponeurotic hematomas are formed; prevention - careful ligation of the vessels at the base (aponeurosis) and the muscle, followed by crossing between the two ligatures; the stump of the vessel must be of sufficient length to prevent the ligature from slipping; in doubtful cases, it is better to additionally suture the vessel;
• injury to the vasa epigastrica inferiora - large vessels located along the outer edge of the rectus abdominis muscles - with displacement from the center of the anterior abdominal wall (white line of the abdomen) during lower median (usually repeated laparotomy), rough additional separation of the rectus abdominis muscles by hand or mirrors during any type of laparotomy; the result is extensive subgaleal hematomas (prevention - tissue dissection only by sharp means, exclusion from practice of "manual" techniques for widening the wound).

If the above vessels are injured, it is necessary to perform careful hemostasis with revision and isolated suturing of the vessels before suturing the anterior abdominal wall.

Thus, the importance of wound infection in the clinical practice of gynecologists cannot be underestimated, since its consequences can be not only moral (prolonged recovery period after surgery, need for dressings, unpleasant subjective experiences), economic, cosmetic aspects, but also subsequent medical problems requiring repeated surgical intervention (formation of hernias), not to mention the possibility of developing wound sepsis.