Reducing infection risk from stitches - the basics

The timing of suture removal is important to avoid infection or discomfort, says Dr Honor Merriman.

Sutures are the traditional method of laceration repair, and are best for irregular lacerations and wounds requiring subcutaneous closure. Non-absorbable sutures need to be removed once the wound has healed.

The length of time the sutures should be left depends on the wound site (see box, right). Prompt removal reduces the risk of suture marks, infection and tissue reaction.

It is reasonable to remove sutures from healed parts of a wound and leave sutures in place longer for parts where healing is not yet complete.

Wound cleansing
Normal saline or tap water are the most suitable agents for cleaning the skin before suture removal. Irrigation with a syringe is the gentlest way to clean the wound.

Antiseptics can be used for cleaning the skin of healed wounds, but they can slow the healing process if the wound is not completely healed.

Suture removal
The suture should be snipped as close as possible to the body so that a minimal amount will be actually pulled through the skin. This reduces the pinching or pulling sensation for the patient. It also reduces the possibility of infection being pulled through on the sutures.

Using sterile forceps with your non-dominant hand, lift the suture at the knot. Using sterile suture scissors, clip the thread close to the skin. Lift the suture out with the forceps. Gently tug on the suture to remove if needed.

Because of the difficulty of achieving the necessary sterile standard with practice autoclaves, most practices use sterile disposable equipment.

Additional measures
Dressing the healed wound is best done with a sterile, non-adherent dressing. Sterile skin-closure strips may be applied to provide continued supplemental wound support after the sutures are removed.

Paracetamol or ibuprofen are good first-line choices for pain relief. Review the patient's tetanus immunisation status.

If five doses of tetanus toxoid have not been given in the past and a booster was not given at the time of suturing, one should be considered.

Antibiotics
Antibiotics are not commonly needed but may be indicated if the wound appears to be infected when the sutures are removed.

Patients with diabetes, alcohol dependency, peripheral vascular disease, asplenia or immunosuppression, including those on oral corticosteroids or chemotherapy, may be more likely to need antibiotics because their ability to fight infection is reduced.

The results of wound swabs are not always helpful in identifying which drug is best.

Flucloxacillin is a good first-line choice for wound infection in non-penicillin-allergic patients.

Co-amoxiclav, or doxycycline plus metronidazole (if penicillin-allergic), are suitable first-line choices for contaminated wounds, such as human bites.

MRSA infection is now occurring in community-acquired infections. These wounds take longer to heal. Vancomycin is a good choice of antibiotic but not all strains are sensitive to it.

Wound closure methods
Because sutures can serve as an entry point for bacteria, they have the highest rate of infection. Other methods of wound closure include surgical staples, skin-closure tapes and adhesive agents.

Absorbable sutures rapidly break down in the tissues and will lose their strength within 60 days.

Surgical staples are quicker, more economical and cause fewer infections than sutures. These need a special device for removal. They are commonly used on scalp lacerations and to close surgical wounds.

Skin-closure strips are associated with a lower rate of wound infection than stitches and they can be applied quickly without the need for local anaesthetic.

The main disadvantages of using skin-closure tapes is that there is less precision in bringing wound edges together than with suturing.

Not all areas of the body can be taped. For example, body areas with secretions such as the armpits, palms or soles are difficult areas to place adhesive strips. Areas with hair are also not suitable for taping.

Adhesive glue is the most recent method of wound repair and is becoming a popular alternative to stitches, especially for children.

Dr Merriman is a GP in Oxford.

Suture removal
When to remove sutures depends on the wound site

  • Facial wounds: 3-5 days.
  • Scalp wounds: 7-10 days.
  • Limbs: 10-14 days.
  • Joints: 14 days.
  • Trunk of the body: 7-10 days.

 

Resources
How to remove stitches or sutures

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