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Wound Infection Differential Diagnoses

  • Author: Hemant Singhal, MD, MBBS, FRCS(Edin), FRCSC; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
Updated: Dec 17, 2015

Differential Diagnoses

Contributor Information and Disclosures

Hemant Singhal, MD, MBBS, FRCS(Edin), FRCSC Consultant Surgeon, Clementine Churchill Hospital; Director of Breast Service, Medanta The Medicity; Senior Lecturer, Department of Surgery, Imperial College School of Medicine

Hemant Singhal, MD, MBBS, FRCS(Edin), FRCSC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.


Kanchan Kaur, MBBS MS (General Surgery), MRCS (Ed), Consulting Breast and Oncoplastic Surgeon, Medanta, The Medicity, India

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Amy L Friedman, MD Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse

Amy L Friedman, MD is a member of the following medical societies: Association for Academic Surgery, International College of Surgeons, New York Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, Association of Women Surgeons, International Liver Transplantation Society, Transplantation Society, American College of Surgeons, American Medical Association, American Medical Womens Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.


Charles Zammit, MD Senior Specialist Registrar, Department of Surgery, Breast Unit Charing Cross Hospital of London, UK

Disclosure: Nothing to disclose.

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Wound infection due to disturbed coagulopathy. This patient has a pacemaker (visible below right clavicular space) and had previous cardiac surgery (median sternotomy wound visible) for a rheumatic mitral valve disorder, which was replaced. The patient was taking anticoagulants preoperatively. Despite converting to low-molecular weight subcutaneous heparin treatment and establishing normal coagulation studies, she developed a postoperative hematoma with subsequent wound infection. She had the hematoma evacuated and was administered antibiotic treatment as guided by microbiological results, and the wound was left to heal by secondary intention.
Abscess secondary to a subclavian line.
Definitions of surgical site infection (SSI).
Factors that affect surgical wound healing.
Large ulceration in a tattoo. A 33-year-old man presented with a superficial ulceration about 4 weeks after a red tattoo on his forearm. Microbial swabs remained negative. His medical history was uneventful and he was in good general health. No reason for this uncommon reaction could be identified. Image courtesy of the National Institutes of Health.
Table 1. Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence[8]
Pathogen Frequency (%)
Staphylococcus aureus20
Coagulase-negative staphylococci14
Escherichia coli8
Pseudomonas aeruginosa8
Enterobacter species7
Proteus mirabilis3
Klebsiella pneumoniae3
Other streptococci3
Candida albicans3
Group D streptococci2
Other gram-positive aerobes2
Bacteroides fragilis2
Table 2: Surgical Wound Classification and Subsequent Risk of Infection (If No Antibiotics Used)[8, 10]
Classification Description Infective Risk (%)
Clean (Class I)Uninfected operative wound

No acute inflammation

Closed primarily

Respiratory, gastrointestinal, biliary, and urinary tracts not entered

No break in aseptic technique

Closed drainage used if necessary

< 2
Clean-contaminated (Class II)Elective entry into respiratory, biliary, gastrointestinal, urinary tracts and with minimal spillage

No evidence of infection or major break in aseptic technique

Example: appendectomy

< 10
Contaminated (Class III)Nonpurulent inflammation present

Gross spillage from gastrointestinal tract

Penetrating traumatic wounds < 4 hours

Major break in aseptic technique

About 20
Dirty-infected (Class IV)Purulent inflammation present

Preoperative perforation of viscera

Penetrating traumatic wounds >4 hours

About 40
Table 3. Recommendations for Prophylactic Antibiotics as Indicated by Probable Infective Microorganism Involved[8, 28]
Operation Expected Pathogens Recommended Antibiotic
Orthopedic surgery (including prosthesis insertion), cardiac surgery, neurosurgery, breast surgery, noncardiac thoracic proceduresS aureus, coagulase-negative staphylococciCefazolin 1-2 g
Appendectomy, biliary proceduresGram-negative bacilli and anaerobesCefazolin 1-2 g
Colorectal surgeryGram-negative bacilli and anaerobesCefotetan 1-2 g or cefoxitin 1-2 g plus oral neomycin 1 g and oral erythromycin 1 g (start 19 h preoperatively for 3 doses)
Gastroduodenal surgeryGram-negative bacilli and streptococciCefazolin 1-2 g
Vascular surgeryS aureus, Staphylococcusepidermidis, gram-negative bacilliCefazolin 1-2 g
Head and neck surgeryS aureus, streptococci, anaerobes and streptococci present in an oropharyngeal approachCefazolin 1-2 g
Obstetric and gynecological proceduresGram-negative bacilli, enterococci, anaerobes, group B streptococciCefazolin 1-2 g
Urology proceduresGram-negative bacilliCefazolin 1-2 g
Table 4. Predictive Percentage of SSI Occurrence by Wound Type and Risk Index*[29]
At Risk


Predictive Percentage of SSI
*Hospital Infection Control Practices Advisory Committee (HICPAC) recommendations (partial) for the prevention of SSIs, April 1999 (non–drug based)
Table 5. American Society of Anesthesiologists (ASA) Classification of Physical Status[30]
ASA Score Characteristics
1Normal healthy patient
2Patient with mild systemic disease
3Patient with a severe systemic disease that limits activity but is not incapacitating
4Patient with an incapacitating systemic disease that is a constant threat to life
5Moribund patient not expected to survive 24 hours with or without operation
Table 6. Data Support Recommendations
Category Description
Category IAWell designed, experimental, strong; recommended (Category I*) clinical or epidemiological best practice; should be studies; adapted by all practices
Category IBSome experimental, fairly strong; recommended (Category II*) clinical or epidemiological best practice; should be studies and theoretical grounds; adapted by all practices
Category IIFewer scientific supporting data; limited to specific nosocomial (Category III*) problems
No recommendationInsufficient scientific personnel judgment for use (Category III*) supporting data
*Previous nomenclature of 1992 CDC guidelines
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