II. Pathophysiology

  1. Colonization of wound sites with normal skin flora is common
  2. Immunocompetent hosts typically heal minor wounds without secondary infection

III. Risk Factors

  1. Contaminated wound (manure, dirt, rust)
  2. Bite Injury
  3. Crush Injury
  4. High risk site (hand or foot)
  5. Bone exposed within Laceration
  6. Prolonged time to skin closure (see above)
  7. Underlying medical condition
    1. Diabetes Mellitus
    2. Chemotherapy
    3. Corticosteroids
    4. Malnutrition
    5. Lymphedema
    6. Peripheral Vascular Disease

IV. Signs

  1. Infection occurs within 48 hours in most cases
    1. However surgical wounds typically do not demonstrate infection in the first few days
  2. Localized infection
    1. Skin erythema
    2. Skin induration
    3. Local skin warmth
    4. Local wound pain
    5. Focal wound tenderness
    6. Purulent wound drainage
  3. Deeper or regional infection
    1. Lymphangitis
    2. Deep tissue abscess
    3. Fascial involvement
    4. Bone or joint involvement (Osteomyelitis, Septic Arthritis)
    5. Muscle or tendon involvement (e.g. Suppurative Tenosynovitis)
    6. Gangrene
  4. Systemic infection
    1. Fever
    2. Vomiting
    3. Tachycardia
    4. Hypotension
    5. Lethargy or other decreased mental status
    6. Metabolic Acidosis or Lactic Acidosis
    7. Leukocytosis

V. Management: General

  1. Wound cleaning with sterile saline
  2. Consider Wound Debridement (e.g. Sharp Debridement, Wet-to-Moist Dressings, Enzymatic Debridement)
  3. Elevate involved wound site
  4. Optimize comorbidities (e.g. Glucose management in Diabetes Mellitus)

VI. Management: Mild Wound Infections

  1. Criteria
    1. Two or more of the localized infection findings above AND
    2. Cellulitis <2 cm from wound edge AND
    3. Limited to superficial tissue or skin and without systemic symptoms
  2. Management
    1. Skin Abscess
      1. See Incision and Drainage
    2. Impetigo and other focal, minor infections
      1. See Impetigo
      2. Topical Antibiotics
        1. Mupirocin 2% (Bactroban) or Retapamulin (Altabax)
        2. Metronidazole 0.75% gel if anaerobic organisms are suspected
      3. Systemic antibiotics may be indicated in some cases (e.g. Cephalexin, Dicloxacillin)
    3. Cellulitis
      1. See Cellulitis for antibiotic selection

VII. Management: Moderate Wound Infections

  1. Criteria
    1. Cellulitis extending >2 cm beyond wound edges OR
    2. Deeper or regional infection findings as above
  2. Management
    1. Cellulitis
      1. See Cellulitis for antibiotic selection
      2. Treat for at least 5 days
    2. Bite wounds
      1. See Dog Bite Infection (includes Cat Bite Infections)
      2. See Human Bite
    3. Burn Injury related infection
      1. See Burn Management

VIII. Management: Severe Wound Infections

  1. Criteria
    1. See systemic infection signs above
  2. Management
    1. Hospitalization in most cases
    2. Initiate Parenteral antibiotics
    3. See Cellulitis for antibiotic selection
    4. Consider infectious disease Consultation

IX. Management: Refractory and Progressive Wound Infections

  1. Criteria
    1. Progressive infection with severe regional and systemic symptoms
  2. Management
    1. Consider Necrotizing Soft Tissue Infection (Necrotizing Fasciitis)
    2. Managed as severe Wound Infection above
    3. See Cellulitis for antibiotic selection
    4. Infectious disease Consultation

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