Avoiding antibiotics with surgical wounds – 8 essentials

How often do you suture a wound and feel the urge to add antibiotics into the treatment protocol? We’ve been used to using and abusing these drugs for too long, and the truth is that there are many situations where we don’t need their help at all.

Posted: 25 June 2020

Avoiding antibiotics with surgical wounds – 8 essentials

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Most fresh wounds will be relatively clean and uncontaminated, and all that is required is some gentle cleaning and assistance to appose the edges. This will often be the best time to suture a traumatic wound.

Without suturing, and after a couple of days, an untreated wound may become inflamed, yellow in appearance and show signs of a slough developing. Neutrophils will provide the first line of defence, by phagocytosing, killing, and digesting bacteria, whilst macrophages break down damaged protein-rich material into a slough. At this stage, if the wound isn’t connecting with any vital structures and the inflammation is isolated to the wound, antibiotics will almost certainly be unnecessary. All that will be required is for the wound to be debrided and cleaned to reduce the bioburden.

If a wound appears to be infected, maybe we should really be checking for evidence of infection first before reaching for antibiotics. By reducing their use to treat wounds today we can help prevent an antibiotic resistance pandemic in the future.

Before using antibiotics on a wound, ask yourself these 7 questions

1. Is the wound clear of organic material? - if not, the use of some antiseptics and antibiotics may be inhibited and become ineffective.

2. Has all debris been physically removed? - if not, it will prolong the inflammation, regardless of whether infection is present or not.

3. Will debridement and decontamination help? – if the answer is yes, then maybe antibiotics are unnecessary.

4. Has all devitalised tissue been removed? - there is evidence that compromised tissues receive sub-optimal concentrations of antibiotics, which may then encourage the formation of resistance to the antibiotics.

5. Can systemic antibiotics reach the wound bed at an effective concentration? – there will be times when the nature of the wound itself may limit the blood supply to the infected tissues.

6. Is the wound infected? – this relies primarily on your clinical judgement and detailed examination. The signs and symptoms of infection in a normal healthy patient are;

  • Pain – this may be new or increasing
  • Erythema – a pink/red appearance compared to surrounding skin
  • Local heat – the area may feel warm to the touch
  • Purulent discharge
  • Pyrexia – this would often be 5-7 days post-surgery or trauma
  • Any evidence of delayed healing or wound breakdown
  • Abscess formation
  • Smell – the tissues often have an unpleasant odour
  • Lymphangitis – always check the local and regional lymph nodes
  • Crepitus – there will be a very characteristic feel in the soft tissues

7. Can you gather some clinical evidence? – this can be achieved by taking samples, so;

  • Swab the wound – if any of the above clinical signs are present, it may be worth taking a sterile swab of the wound to check for evidence of bacterial or fungal pathogens. A technique which involves rotating the swab over an area of the wound while applying a small amount of pressure is used to capture any exudate.
  • Use a balanced interpretation - microbiology reports should not read in isolation and the condition of the patient and the wound must always be taken into account. Surgical wounds tend to be colonised by a single pathogen, whereas chronic wounds can contain multiple bacterial organisms.

8 ways to reduce the use of antibiotics when suturing wounds

Fortunately, there are some particularly effective ways to minimise the need for antibiotics when suturing wounds, and most of these are simple to achieve;

  1. Clip the surgical area – always clip and clean the area, making sure you leave no hairs or debris. Cleaning is best achieved using chlorhexidine, but make sure the correct concentrations are used.
  2. Lavage – any gross decontamination can be removed by washing with large volumes of clean water. The final wash can be with sterile saline or lactated ringers.
  3. Debride as required – surgically remove any damaged tissues or foreign objects from a contaminated wound until you have healthy looking margins. In most cases, necrotic tissue must be removed before repair and healing can occur.
  4. Edge the wound – when suturing skin, always make sure the edges meet without the risk of undermining or rolling. If the edges don’t meet and align, there will be insufficient viable tissue to support epithelisation, which will result in necrosis and infection.
  5. Maintain a sterile operating room - all surgical team members must wear clean and sterile protective equipment. This includes sterile surgical gowns, masks and gloves to establish bacterial barriers. These barriers protect the patient from the transmission of microorganisms from the surgical team.
  6. Provide a moist environment – this allows wounds to heal faster and less painfully than in a dry environment. If the wound is kept hydrated with appropriate dressings, epidermal cell migration and epithelialisation will be effective.
  7. Avoid excessive pressure – ensure that any dressings that are used are applied carefully, to provide protection without causing too much and prolonged pressure. Dressing are best checked and removed after a day or two.
  8. Essential nutrition – always check and ensure that the owner is feeding the best diet. If a wound is not healing as expected and you are in any doubt about the nutritional status of your patient, check the albumin and white blood cells and use them as markers for malnutrition. Adequate protein in the diet is essential for cell growth and healing.

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