Prevention of Orthopaedic Infections

Prevention of Orthopaedic Infections - Bug Battle Basics

• Surgical Site Infection (SSI): CDC defined.
  • Superficial Incisional: Skin/subcutaneous; within 30 days.
  • Deep Incisional: Fascia/muscle; 30 days (no implant), 1 year (implant).
  • Organ/Space: Manipulated anatomy (joint, bone).
• Prosthetic Joint Infection (PJI): Infection involving implant/periprosthetic tissue.
• Common Pathogens: Staphylococcus aureus (MSSA/MRSA), CoNS, Gram-negatives (Pseudomonas).
• Risk Factors:
  • Patient: Diabetes, obesity, smoking, malnutrition, immunosuppression.
  • Procedure: Prolonged surgery, poor asepsis, implants.

⭐ Staphylococcus aureus is the most common pathogen in orthopaedic infections, including SSI and PJI.

Prevention of Orthopaedic Infections - Pre-Surgery Armor Up

• Patient Optimization: Minimize SSI risk.
  • Smoking: Cessation ≥4 wks pre-op.
  • Diabetes: Control HbA1c < 7% (better healing).
  • Nutrition: Correct malnutrition & anemia.
  • Obesity: Manage BMI >35-40 kg/m² (counsel SSI risk).
  • MRSA/MSSA Decolonization (if carrier):
    • Mupirocin 2% intranasal: BID x 5 days pre-op.
    • CHG body washes: Daily x 3-5 days pre-op.

• Preoperative Antibiotic Prophylaxis:
  • Timing: IV antibiotics within 60 mins pre-incision. 📌 "An Hour to Empower!"
  • Agent: Procedure-specific, local antibiogram, patient allergies.
  • Re-dosing: Surgery >3-4h (or >2 drug half-lives), or blood loss >1500mL.

⭐ Vancomycin infusion should start within 120 minutes before surgical incision due to longer infusion time.

Prevention of Orthopaedic Infections - OR Germ Warfare

• Operating Room (OR) Environment:
  • Positive pressure ventilation system.
  • Laminar airflow to reduce airborne contaminants.
  • Air changes: ≥15-25 per hour.
  • Minimize OR traffic and door openings.
  • UV germicidal irradiation (adjunctive).
• Surgical Team Preparedness:
  • Hand hygiene: meticulous surgical scrubbing or alcohol-based rubs.
  • Surgical attire: sterile, impermeable gowns, masks, headgear, shoe covers.
  • Double gloving, especially for implant surgery.
• Patient Skin Preparation:
  • Antiseptic agents: Chlorhexidine-alcohol is often preferred.

  ⭐ Chlorhexidine-alcohol is generally preferred over povidone-iodine for surgical skin preparation due to superior efficacy and residual activity.

• Meticulous Surgical Technique:
  • Atraumatic tissue handling to preserve vascularity.
  • Obliteration of dead space.
  • Copious irrigation to remove debris.
  • Effective hemostasis.
  • Minimize operative time.
  • Appropriate suture material and wound closure.
• Specific Prophylaxis:
  • Antibiotic-laden bone cement (ALBC) for selected high-risk arthroplasty cases.

Prevention of Orthopaedic Infections - Healing's Watchful Eye

• Wound Care:
  • Sterile dressings: Maintain until dry or per protocol.
  • Incision care: Keep clean, dry; educate patient.
• Suture/Staple Removal: Typically 7-14 days post-op; site-dependent.
• Antibiotic Prophylaxis:
  • Discontinue within 24 hours post-op, even with drains.
  • ⭐ > Prophylactic antibiotics should generally be discontinued within 24 hours after surgery, even with drains in place.
• Monitoring for Infection Signs:
  • Local (📌 "RSPD" + Warmth): Redness, Swelling, ↑Pain, Discharge (purulent), Warmth.
    • Visual aid:
  • Systemic: Fever (>38°C), chills, tachycardia, ↑WBC, ↑CRP/ESR.
• Early Action:
  • Promptly manage superficial SSI to prevent deep infection.
  • Culture if suspected_

High‑Yield Points - ⚡ Biggest Takeaways

• Preoperative optimization: control diabetes (HbA1c <7%), stop smoking, ensure nutrition.
• Antibiotic prophylaxis: within 60 mins pre-incision (120 mins for Vancomycin/FQ); Cefazolin common; stop ≤24 hrs.
• Intraoperative sterility: laminar air flow, minimal OR traffic, CHG-alcohol skin prep.
• MRSA decolonization (mupirocin, CHG baths) for high-risk procedures like arthroplasty.
• Postoperative wound care: sterile dressings, monitor for SSI signs.
• Open fractures: urgent debridement and broad-spectrum antibiotics.