Prevention of surgical site infections in orthopaedic surgery and bone trauma: state-of-the-art update

doi:10.1016/j.jhin.2012.12.014

Journal of Hospital Infection

Volume 84, Issue 1, May 2013, Pages 5-12

https://doi.org/10.1016/j.jhin.2012.12.014 Get rights and content

Summary

Prevention of surgical site infection in orthopaedic surgery and bone trauma has some hallmarks not shared with other surgical disciplines: low inoculum for implant infections; pathogenicity of coagulase-negative staphylococci and other skin commensals; possible haematogenous origin; and long post-discharge surveillance periods. Only some of the many measures to prevent orthopaedic surgical site infection are based on strong evidence and there is insufficient evidence to show which element is superior over any other. This highlights the need for multimodal approaches involving active post-discharge surveillance, as well as preventive measures at every step of the care process. These range from preoperative care to surgery and postoperative care at the individual patient level, including department-wide interventions targeting all healthcare-associated infections and improving antibiotic stewardship. Although theoretically reducible to zero, the maximum realistic extent to decrease surgical site infection in elective orthopaedic surgery remains unknown.

Introduction

Healthcare-associated infections (HCAIs) are relatively rare in orthopaedic and trauma surgery compared with other surgical wards. The current lifelong infection risk for primary hip and knee arthroplasties is around 1% and increases to 2–5% for revision arthroplasties, shoulder arthroplasties, and fracture fixation devices (Table I). By contrast, the risk for surgical site infection (SSI) following colon surgery can be as high as 20%.¹ According to a large French prevalence study, the relative risk of SSI following genitourinary, cardiovascular, gynaecological, and gastrointestinal surgery compared with orthopaedic surgery was 2.1, 2.4, 2.6, 3.4, and 4.8, respectively.¹ SSIs are often associated with a high burden on patients and hospitals in terms of morbidity, mortality, and additional costs.² Osteo-articular infections are also difficult to treat and associated with lifelong recurrence risks of around 10–20%, particularly in the case of multi-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA).³

Prevention remains of the utmost importance. SSI prevention in orthopaedic surgery has certain specificities unknown to general surgery: low inocula for implant-related foreign body infections; pathogenicity of skin commensals; a possible haematogenous origin for some infections; and the necessity for a prolonged, post-discharge surveillance period with a minimal follow-up of one year for implant-related surgery.4, 5, 6, 7 The aim of this review was to focus on specific aspects of SSI prevention in adult orthopaedic and trauma patients and highlight important epidemiological features.

Section snippets

Literature review

We conducted a literature search including search engines such as Google and electronic resources such as PubMed to identify English, French, and German language publications published before 31 December 2011 using the MeSH terms ‘infection’, ‘orthopaedic’ or ‘orthopedic’, and ‘prevention’ alone and in different combinations. PubMed yielded 1712 reports, and almost a million hits were displayed on Google. Results retrieved by PubMed were screened for pertinence and the presence of redundant

Active surveillance and multimodal interventions

Multimodal strategies targeted at SSI prevention are associated with the highest impact. These interventions, sometimes in the form of so-called ‘bundles’ or safety checklists, do not need to cover all potential risk factors. For example, De Lucas-Villarubia et al. implemented admission screening for MRSA carriage, preoperative decolonization, improvement of antibiotic prophylaxis, and post-discharge surveillance.⁴⁵ With these simple measures and an institution-wide awareness of the facility's

Screening for S. aureus carriage with subsequent decolonization

Screening and subsequent decolonization of patients before and after surgery remain controversial for general surgery.⁴ If the orthopaedic literature is considered separately, available data suggest that this may be cost-saving specifically in this group of patients and may allow the eradication of MRSA or meticillin-susceptible S. aureus carriage.17, 47, 46 It is possible that the lower inoculum needed for implant infections might be one reason for more convincing results compared with other

Preoperative bathing or showering

There is little evidence that preoperative showering with an antiseptic agent reduces SSI rates, although it has been shown to reduce skin colonization.⁷ The US Centers for Disease Control and Prevention (CDC) recommend that patients shower or bathe with an antiseptic agent prior to surgery.⁷ A Cochrane review including six trials with 10,000 participants found no evidence for the superiority of preoperative bathing and showering versus placebo.⁵²

Preoperative skin preparation

Preoperative skin preparation in the operating

Conclusion

All healthcare-associated infections must be targeted to reduce their incidence. This requires multidisciplinary commitment, dedicated teams, surveillance networks, and an optimum policy concerning the reduction of antimicrobial use to actual evidence-based levels. From an academic standpoint, we still lack a complete understanding of exactly when the surgical site starts to develop infection and the premises that drive microbial colonization to infection. There is certainly a need to improve

Acknowledgement

We thank R. Sudan for editorial assistance.

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The main objective of this study was to assess the sanitary measures of operating theaters using next-generation sequencing.
Air was sampled from the operating room for the whole duration of 10 surgical days of “clean” (no infection cases) procedures (6 hip/knee arthroplasty and 4 spine cases). Controls consisted of samples at the beginning of the day (1 hour before the surgery started) and at the end of the day after terminal cleaning. One additional control sample, consisting of a culture swab that was opened and exposed to the air for 5 seconds, was collected at each time point. All samples were sent for next-generation sequencing analysis (16S rRNA sequencing) for bacterial identification.
Overall, 306 samples were collected (159 controls and 147 experimental). Microbial DNA was detected in only 1 control sample, while 18 (12.2%) experimental samples were positive for microbial DNA. The most common organisms retrieved were Escherichia coli (6/18, 30%), Cutibacterium acnes (3/18, 15%), and Pseudomonas aeruginosa (2/18, 11.1%). There was no difference in positive samples between arthroplasty and spine cases (P > .05).
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ReviewPrevention of surgical site infections in orthopaedic surgery and bone trauma: state-of-the-art update

Summary

Introduction

Section snippets

Literature review

Active surveillance and multimodal interventions

Screening for S. aureus carriage with subsequent decolonization

Preoperative bathing or showering

Preoperative skin preparation

Conclusion

Acknowledgement

J Infect

J Hosp Infect

J Hosp Infect

J Hosp Infect

J Hosp Infect

Int J Surg

J Hosp Infect

J Hosp Infect

J Hosp Infect

Lancet

J Orthopaedic Nurs

J Hosp Infect

Am J Surg

Asian J Surg

The standardized incidence ratio as a reliable tool for surgical site infection surveillance

Infect Control Hosp Epidemiol

The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost

Infect Control Hosp Epidemiol

Outcome of orthopedic implant infections due to different staphylococci

Int J Infect Dis

Preventing surgical site infections

Expert Rev Anti Infect Ther

Foreign body infections due to Staphylococcus epidermidis

Ann Med

Guideline for prevention of surgical site infection, 1999

Infect Control Hosp Epidemiol

National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004

Am J Infect Control

Prevention of deep periprosthetic joint infection

Instr Course Lect

Prevention and treatment of surgical site infection. Guideline CG74

Prophylactic antibiotics in hip and knee arthroplasty

J Bone Joint Surg Am

Prophylactic antibiotics in orthopaedic surgery

J Am Acad Orthop Surg

Surgical hand antisepsis to reduce surgical site infection

Cochrane Database Syst Rev

Preventing infection in total joint arthroplasty

J Bone Joint Surg Am

Perioperative cefamandole prophylaxis against infections

J Bone Joint Surg Am

Single-versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed fractures: a meta-analysis

J Orthop Trauma

Surgical site infection prevention and control: an emerging paradigm

J Bone Joint Surg Am

Methicillin-resistant staphylococci in clean surgery. Is there a role for prophylaxis?

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A systematic review and economic model of switching from non-glycopeptide to glycopeptide antibiotic prophylaxis for surgery

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Remission after treatment of osteoarticular infections due to Pseudomonas aeruginosa versus Staphylococcus aureus: a case-controlled study

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Gram-negative versus gram-positive prosthetic joint infections

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Prosthetic joint infection in solid organ transplant recipients: a retrospective case–control study

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Does cement increase the risk of infection in primary total hip arthroplasty? Revision rates in 56,275 cemented and uncemented primary THAs followed for 0–16 years in the Norwegian Arthroplasty Register

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Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases

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Review
Prevention of surgical site infections in orthopaedic surgery and bone trauma: state-of-the-art update