I was wondering if you could add another part into the “skin” section. I feel wounds deserve their own section. I feel
there is not a consensus among doctors in general in terms of the best approach for infected wounds. Or is it as simple
as approaching it the same way as standard infected wound like cellulitis – unless it is a closed fist injury or on a
I would also like to know what the policy should be on soft tissue wounds that have been sutured which then get infected.
At what point do we remove the sutures? Is it as soon as infection is suspected or can you watch and wait and manage with
I struggled to find much evidence online on my article search. Most of the evidence was for surgical wound infections
instead of soft tissue injuries.
I had a discussion with a patient today who had developed infection post-suturing. He came in previously with signs
of infection on Day 3 (Day 1 = sutured) and was already on cephalexin for infection prophylaxis and was switched from
that to flucloxacillin 1g four times daily. He was reviewed again on Day 5 and the doctor he saw advised him the sutures
needed to be left in longer than normal.
I reviewed him on day 8 (today) and he still had the sutures in place in a wound that still looked red and infected
but improved from previously. A colleague of mine who worked as an orthopaedic registrar, advised sutures need to be removed
when infected and that’s what I thought was standard practice.
However, I would very much appreciate your opinion on this given the lack of evidence I could find online.
Response from the bpacnz editorial team:
1. General guidance on wound management
Wounds comprise a diverse range of skin lesions. Wound management is guided by both the type of wound as well as patient
characteristics which may delay wound healing, e.g. underlying medical conditions, older age, obesity, smoking, and poor
nutrition. All open skin wounds are colonised by bacteria, however, this does not mean all wounds are infected. Inflammation
occurs in all wounds during healing and minor swelling, erythema and increased warmth at the site is normal and should
not be confused with clinical infection. Similarly, sutures can provoke a local skin reaction; a small amount of redness
and irritation around sutures is not necessarily indicative of infection.
There are four classes of wounds:1
Traumatic wounds are defined as contaminated if they are less than four hours old at time of medical review, and dirty
if more than four hours old.2 Some traumatic wounds, however, are more prone to infection than others: shearing
force wounds, such as lacerations, tend to heal well, while avulsion injuries heal poorly and crush injuries both heal
poorly and are prone to infection.3 While clinicians need to consider each case individually, antibiotic prophylaxis
is often recommended for contaminated and dirty wounds.4
Empiric antibiotic choices, for either traumatic or non-traumatic wounds, are guided by the type of wound, its location,
potential pathogens and local antibiotic susceptibility. Susceptibility may differ by geographical area or location, e.g.
MRSA is more common in some residential care facilities, and the prevalence of other multi-drug resistant organisms is
increasing in New Zealand.5 Laboratories may publish local antibiotic sensitivities, while the Institute of
Environmental Science and Research Ltd (ESR) collates regional laboratory data and publishes this information quarterly.6
Flucloxacillin or cefalexin are the mainstays of empiric antibiotic treatment for skin infections, including wounds.
Alternatives include erythromycin and co-trimoxazole (if MRSA is present).
Depending on the clinical circumstances, a wound swab may be required in addition to empiric antibiotics. It may be
appropriate to change to a narrower spectrum antibiotic when swab results become available, especially if a long course
of antibiotics is anticipated. Wounds failing to respond to empiric treatment should be swabbed, with the culture result
guiding antimicrobial treatment; note any empiric therapy on the laboratory form.
2. Managing wounds with sutures
When considering wound infections, surgical and traumatic wounds are often grouped together as much of the advice is
applicable to both types. Wound infections should be evaluated by severity; patients with mild infections may have increased
redness, swelling and pain at the incision site. More severe infections may also have spontaneous drainage from the wound,
as well as causing systemic symptoms of fever and tachycardia with associated lymphocytosis. In general, mild wound infections
can be cleaned and observed, without suture removal.2 Patients with moderately infected wounds should have
the sutures removed and incisions opened and drained, while those with deep infections may require referral for washout
Wound infections do not always require antibiotics, and many wounds can be managed by cleaning, or suture removal and
opening and drainage of incisions.2, 4 Antibiotics are recommended for the treatment of infected surgical or
traumatic wounds if the patient has systemic signs including a fever >38°C, tachycardia >110/min, erythema and/or
induration > 5 cm from the incision, or necrosis.4 Appropriate antibiotic therapy should be effective in
treating wound infections as long as there is a good blood supply at the wound site. This may not always be the case,
e.g. if necrotic tissue is present.
Written guidance cannot, however, replace evaluation of individual patients by an experienced clinician. If unsure,
clinicians are advised to discuss their concerns with a senior colleague, an orthopaedic surgeon, or a wound care specialist.
The antibiotic guide is currently under review and will be updated later this
year. The current version of the guide is available from: bpac.org.nz/antibiotics
For more information on wound management see: