Duke IR Infected port management guidelines

Aug 23, 2021

 Patient referred for port removal due to infection. Open pocket, remove port. Is there pus?

• No : Irrigate with saline. close incision primarily.
• Maybe: Swab pocket and send for cx. Irrigate with saline(1). Close incision primarily.
• Yes: Swab pocket and send for cx. Irrigate with saline(1). Leave incision open – do not pack pocket with gauze (2). Cover wound with gauze and tegaderm (3). Rx oral abx (4)

 ¹ Duke recommends against use of antibiotic irrigant. The RCT literature comparing abx solution vs saline irrigation on infected wounds and abscesses have shown no difference in outcomes but in some cases impaired healing with antimicrobial solutions.

 ² All of the RCT’s and meta-analysis show no benefit to packing versus no packing for subcutaneous abscesses. Also incurs substantial pain, and logistics can be formidable

 ³ The nurses should give the patients one week’s worth of gauze and tegaderm for daily changes – shower OK with tegaderm, then change for new dressing and tegaderm. By then, it should have ceased any drainage and scabbed over – if not, or if site becomes more red/swollen/painful, patient should contact us for inspection.

 ⁴ Rx Keflex 500mg qid x 10d OR Clindamycin 300mg PO qid OR doxycycline 100mg PO bid OR Bactrim DS 10mg/kg per day divided into bid dosing based on trimethoprim component. Patients with bacteremia/sepsis should be inpatient with IV abx. While the RCT data for benefit of oral abx is variable for I&D’d abscesses, the ID Societal guidelines recommend abx for immunocompromised (i.e. the port population). ID societal guidelines also recommend swab culture of pus, so that we know what to prescribe in case the infection persists or recurs.

Additional notes:

• A small minority of patients may need packing initiated if they continue to have a purulent wound after trial of non-packing, or if there is actually necrotic tissue (in this latter case, packing can be done for just one episode at time of removal then remove next day).
• For large gaping wounds after port removal, reasonable to put in some sutures to diminish the size of the wound (whilst keeping open a passage for drainage of residual pus) and decrease time to resolution if desired. It is notable that several RCT’s suggest that primary closure after abscess I&D plus systemic abx do not incur a higher rate of re-abscess formation(!)