Wound infection: treatment

Tactics of management of patients with wound infection. There are different views on managing patients with wound infection. The discrepancy is mainly related to 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 with perforated polyvinyl chloride drainage and prolonged washing with antiseptics;
• as early as possible closure of the wound with the help of primary, primary delayed, early secondary sutures or skin plasty;
• general and local antibiotic therapy;
• increase of specific and nonspecific reactivity of the organism.

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

Surgical treatment of the wound. Primary purulent wounds are wounds, formed after surgery for acute purulent processes (opening abscesses, phlegmon), and after dilution of the edges of the postoperative wound due to suppuration. These can be wounds on the front abdominal wall, perineum.

Surgical treatment of the wound with resection of necrotic tissues prevents the evacuation and formation of extensive defects of the aponeurosis.

Principles of purulent wound treatment:

• adequate anesthesia;
• strict observance of asepsis;
• wide opening of the wound and revision of pockets and fouling not only in the subcutaneous fat tissue, but also in the subpopneurotic space;
• removal of pus, hematomas, ligatures, sanitation of the wound with antiseptic solutions;
• removal of all non-viable purulent-necrotic tissues - tissues with purulent melting (macro- and microabscesses); Necrotic tissues are subject to mandatory removal (areas of "black" color);
• the appearance during the treatment of bleeding (necrotic tissues are not blood supplying) serves as a correct indicator of the correctness of determining the tissue viability limit;
• careful haemostasis;
• change of tools, linen;
• re-sanitation of the wound;
• layer-by-layer stitching of the wound with infrequent seams;
• the principle position is the rejection of all types of passive drainage in case of wound infection (tu-rubbers, rubber bands, tubes, "bundles" of tubes, tampons); (Petrov VI, 1912) that in 6 hours gauze swabs are transformed into pus-impregnated plugs, not only not possessing any sanifying properties, but also preventing the natural outflow of the exudate, the accumulation and absorption of which leads to the appearance of symptoms of purulent-resorptive fever;
• if it is impossible to conduct aspiration-flushing drainage (lack of apparatus), the patient should be recommended to be in the natural position - on the opposite side or on the abdomen, and also to periodically probe and dilute the skin edges of the wound;
• "Dry" management of the cutaneous wound - treatment of the skin with a solution of brilliant green or potassium permanganate;
• mandatory wearing of the bandage;
• removal of secondary joints on the 10th-12th day.

If you superimpose sutures on the wound after its surgical treatment is not immediately possible, it is advisable to conduct an open wound sanation. To this end, we wash the wound with antiseptic solutions, and then we apply the gasket with enzymes (trypsin, chymotrypsin) moistened with physiological saline at the beginning two times a day, then once, which contributes to early rejection of purulent-necrotic tissues, enzymatic purification wounds and the emergence of fresh granulations.

By cleansing the wound (as a rule, this occurs within 5-7 days) produce suturing and close the wound, imposing the so-called early secondary sutures. Stitches are applied according to the previously described technique, with the only difference that, as a rule, there is no longer a need for a wide revision of the wound and necrectomy. Good anesthesia, compliance with aseptic rules, sanitation of the wound with dioxidine, overlapping of rare sutures with careful matching of the edges of the wound, subsequent probing and "dry" treatment of the sutures - this is usually required to obtain a good surgical and cosmetic result when the wound is difficult to distinguish from the healed by primary tension .

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

Sutures are removed on the 10th -12th day, often already outpatient.

In the presence of hematomas of the anterior abdominal wall of large dimensions, their emptying is performed under operating conditions under anesthesia. Dilate the edges of the cutaneous wound, remove the seams from the aponeurosis. As a rule, it is not possible to find a bleeding vessel in the immobilized tissues, besides, it is thrombosed or mechanically compressed by this time by a hematoma. An adequate benefit in this case is the removal of blood and clots, fragments of suture material, sanation with a solution of dioxidine and layer-by-layer stitching of the anterior abdominal wall by infrequent sutures. In case of diffuse bleeding of tissues, as well as in case of hematoma suppuration, a tube for aspiration-flushing drainage is inserted into the submaxoneurotic space, in others - it is limited to the traditional application of cold and cargo.

Similarly, we also treat cases of haematomas (suppurating hematomas) of the perineum and vagina. In the postoperative period we carry out early activation of patients, appointments are supplemented with douching (twice a day).

Our rejection of passive management of patients with wound infection is also fundamental: discharge of patients with unhealed wounds and recommendations of various variants of palliative interventions, for example, bringing the edges of the wound together with a band-aid, etc. Etc., as well as dressings at the place of residence.

It is known that the epithelium grows on the surface of granulations with a low speed - 1 mm around the perimeter of the wound in 7-10 days. In elementary counting, the diastase between the edges of the wound is fully epithelialized no earlier than 2 months later.

All these months the patients are "tied" to the clinic, visiting the surgeon at least once every three days, they are limited in hygienic procedures, sometimes the patients are forced themselves (or by the efforts of relatives) to make dressings. And this is not to mention the reduction of surgical (the possibility of forming hernias) and cosmetic (broad deforming scars) effects of surgery and moral costs. Unlike patients with passive management of wound infection, patients with secondary seams (if seams are not removed in the hospital) are visited by the surgeon no more than 2-3 times - to monitor the condition of the joints and remove them.

A medicamentous 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, the phase of the wound process.

In the stage of infiltration and suppuration, antibiotics are indicated. In the presence of an antibiotic, the treatment is carried out with the most energetic course, most sensitive to the pathogen (with observance of single, daily and course doses of 5-7 days duration). In the absence of bacteriological studies, empirical therapy is performed, taking into account the clinical course of wound infection. It is most expedient to use lincosamides, which have a wide spectrum of action on gram-positive and anaerobic flora.

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

In severe cases, they are prescribed in combination with aminoglycosides with a high selective sensitivity for 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 grams, a daily dose of 0.9 g, a course dose of 4.5 grams, gentamicin in a single dose of 0.08 g, a daily dose of 0.24 g, a course dose of 1.2 g).

It is also highly effective to administer fluoroquinolones, for example, ciprofloxacin 200 mg twice intravenously, in severe cases in combination with metrogil, 0.5 g (100 ml) 3 times a day.

In the case of Pseudomonas aeruginosa, the administration of drugs with high antipseudomonas activity - cephalosporins III generation, eg 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, daily dose 3 g, the course dose of 15 g.

In more light cases, lincosamides or fluoroquinolones are administered orally, for example, clindefer 0.6 g 3 times daily or ciprofloxacin (cilix) 0.5 g 2 times in combination with trichopole 0.5 g twice daily for 5 days.

Prevention of wound infection

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

To avoid wound infection, you must clearly adhere to a number of principles for surgical intervention:

• carry out thorough hemostasis;
• Treating the tissues with care, minimizing their trauma;
• avoid excessive coagulation;
• avoid imposing frequent (less than 0.6 cm), tug-of-war;
• use suction;
• irrigate the subcutaneous tissue with an antiseptic solution of dioxidine at the end of the operation.

Knowledge of the anatomy of the anterior abdominal wall helps to avoid hemostasis defects, leading to the development of hematomas. The risk of hematoma formation is:

• insufficient hemostasis of vasa epigastrica superficialis during pfannenstil abdomen (located in the subcutaneous tissue of the corners of the wound), which can cause hemorrhage from the wound and the formation of subcutaneous hematomas (prophylaxis - careful donation, if necessary with stitching of the vessels);
• Numerous vessels of different caliber feeding the rectus muscles intersect in the abdomen in Pfannenstil, when the aponeurosis is separated from the direct muscles of the abdomen, and subaponeurotic hematomas are formed; prophylaxis - careful ligation of the vessels at the base (aponeurosis) and muscle, followed by the intersection between the two ligatures; the stump of the vessel should be of sufficient length to prevent slippage of the ligature, in doubtful cases it is better to flush the vessel;
• vasa epigastrica inferiora - large vessels located along the outer edge of the rectus abdominal muscles - when displaced from the center of the anterior abdominal wall (white abdominal line) with lower-median (often repeated abdominal), gross additional dilution of the rectus abdominal muscles by hands or mirrors for any kind of abdominal cavity ; the result is extensive subpanoneurotic hematomas (prophylaxis - dissection of tissues only by acute route, exclusion from practice of "manual" methods of widening the wound).

When injuring the above vessels, it is necessary to carry out a thorough hemostasis with revision and isolated stitching of the vessels before suturing the anterior abdominal wall.

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