• By Nicholas Fletcher, MD, D’MitriSofianos, BS, Marschall Brantling Berkes,BS, and William T. Obremskey, MD, MPH• Investigation performed at VanderbiltOrthopedic Trauma, Nashville, Tennessee• J Bone Joint Surg Am. 2007;89:1605-18
AIM• The authors reviewed more than 180 articlesand they present the best available evidenceregarding the use of use of preoperativeantibiotics before elective and emergentorthopaedic operations, preoperative skinpreparation of the patient and surgeon,operating-room issues, wound closure, operativedrainage, and use of dressings in the hope that itwill help physicians to reduce the incidence ofpostoperative wound infection.
• They also provided a level of evidencegrade for individual studies.• Gr –A: good recommendation• Gr- B: fair• Gr- C: poor or conflicting evidence• Gr- I: Inadequate evidence.
ANTIBIOTIC ISSUES• Multiple prospective double blind studiessupport the use of AB prophylaxis forclosed & elective surgery.• In open # AB effective as long as theytarget the usual infecting org.• Choice: closed & elective; cefazolin orcefuroxime.
Open injuries• SIS & EAST• Type 1; class 1 cephalosporin• Type 3; coverage for Gr neg organism.• Type 2 : controversy.• Use of gentamycin once a day dosage forall gr 2&3.
Vancomycin / clindamycin• No comparitive studies.• Not recommended.USE OF PENICILLIN
TIMING• Adm with in sixty mints prior to the incision& ideally as near to the time of incision aspossible.• An additional intraoperative dose isadvised if the duration of the procedureexceeds one to two times the half-life ofthe antibiotic or if there is substantial bloodloss during the procedure.
Vancomycin usuage• Started within two hours prior to theincision because of its extended infusiontime.• warranted for certain procedures ininstitutions where methicillin-resistantStaphylococcus aureus infection is animportant problem or if the patient hasidentifiable risk factors,such as recenthospitalization, renal disease, or diabetes.
DURATION• Minimize the duration.• Most studies suggest 24 hr duration forclosed # & elective.• The proper duration of antibioticprophylaxis for open fractures is not wellestablished• Type 1: 24 hrs• Type 3: 48 – 72 hrs.
• Multiple studies have shown thatextending antibiotic prophylaxis mayactually increase the risk of resistantpneumonia and other systemic bacterialinfections
LOCAL ANTIBIOTICS• No major prospective randomized controltrials have shown a benefit to the use oflocal antibiotics compared withintravenous systemic antibiotics, butmultiple retrospective series havesuggested benefits of local antibiotics.
GRADE A• Broad-spectrum antibiotics should beadministered within one hour of incisiontime and may be continued up to twenty-four hours postoperatively. Longerantibiotic prophylaxis is not warranted inelective procedures or closed fracture care
• Patients with an open fracture shouldreceive antibiotics urgently, andadministration should be continued fortwenty-four hours postoperatively. A first-generation cephalosporin should be usedfor all open fractures when not otherwisecontraindicated
GRADE B• Vancomycin appears to be equivalent to afirst-generation cephalosporin in theprevention of perioperative infection whenthere is no history of methicillin-resistantStaphylococcus aureus infection
GRADE C• Local antibiotics may help reduce the rateof infection and osteomyelitis inassociation with open fractures• Vancomycin may be used as antibioticprophylaxis in patients with a beta-lactamallergy
GRADE I• Aminoglycosides may decrease theprevalence of infection in association withGustilo and Anderson type-II and III openfractures.• There is inadequate evidence to supportthe use of penicillin to prevent clostridialinfection in patients with a severelycontaminated open fracture
• There is inadequate evidence to suggestthat either clindamycin or vancomycin issuperior to the other for antibioticprophylaxis in patients with beta-lactamallergy
PREOPERATIVE PREPARATION• Prep hair removal• No difference in the rate of postoperativeinfections between procedures precededby hair removal and those performedwithout hair removal. Whenever hair isremoved,clippers, rather than a razor,should be used at the time of surgery.
SKIN ANTISEPSIS - patients• Chlorhexidine gluconate and povidone-iodineboth reduce bacterial counts on contact;however, this effect is sustained longer in skincleaned with chlorhexidine.• Furthermore,unlike chlorhexidine gluconate, theiodophors can be inactivated by blood or serumproteins and should be allowed to dry in order tomaximize their antimicrobial action.• Alcohol is an excellent antimicrobial and hasgermicidal activity against bacteria, fungi, andviruses.
• In foot and ankle surgery, The use of a brush toapply the cleansing agent was also superior tothe use of a standard applicator in reducing thenumber of positive cultures of specimens fromweb spaces.• povidone-iodine may impair wound-healing• Conc 0.5% (1/20th) of those used in clinicalpractice, to be extremely toxic to fibroblasts andkeratinocytes
surgeon• Comparison of aqueous alcohol hand rubs withthat of traditional povidone iodine orchlohexidine gluconate scrubbing with brushshows• There was no difference in wound infection rates(2.44% for the alcohol group compared with2.48% for the povidone-iodine or chlorhexidinegluconate group), but physician compliance withthe alcohol protocol was better than that with theother protocol (44% compared with 28%; p =0.008), and there were fewer complaints aboutskin dryness and irritation.
• Alcohol decreased the skin damage andrequired less time.• prolonged use of alcohol andchlorhexidine gluconate rubs had betterantibacterial efficacy than both traditionalpovidone-iodine and traditionalchlorhexidine gluconate scrubbingregimens
OCCLUSIVE DRAPES• literature pertaining to iodophorimpregnated drapes has shown areduction in wound contamination withoutany concurrent decrease in woundinfection.
IRRIGATION• High pressure pulsatile lavage is moreeffective than low-pressure pulsatilelavage for removing particulate matter,bacteria, and necrotic tissue.• This effect is more pronounced incontaminated wounds treated in a delayedmanner.
• Studies suggested that high-pressurepulsatile lavage should perhaps bereserved for severely contaminatedwounds or for open injuries for whichtreatment will be delayed.• Low-pressure irrigation should be used ifcontamination is minimal or treatment isimmediate.
• Detergents such as castile soap orbenzalkonium chloride are effective indecreasing the burden of bacteria inmusculoskeletal wounds because of theirsurface-active properties.• The detergents act by disruptinghydrophobic and electrostatic forces,thereby inhibiting the ability of bacteria tobind to soft tissue and bone.
OPERATING ROOM• Multiple basic-science studies have shownthat ultraviolet light decreases thenumbers of colony-forming units.• Berg et al. found ultraviolet light to beeven more effective than a laminar-flowventilation system in decreasing airbornebacterial load.
• The greatest source of airborne bacteria is theoperating room personnel, with ears and beardsbeing the two areas most likely to shed bacteria.• Men shed a greater number of bacteria perminute than postmenopausal women, andpremenopausal women shed even fewerbacteria.• The number of bacteria shed by operating roompersonnel can be decreased by using airexhaust systems or completely covering earsand beards.
• The use of wraparound gowns andsynthetic gowns decreases the number ofcolony-forming units compared with thatassociated with the use of cotton gowns oroperatingroomclothing.• Blom et al. recommended the use of non-woven disposable drapes or wovendrapes with an impermeable layer belowthem for surgical draping.
• Average number of colony-forming units inan operating room was increased whenthe doors were left open and thatintermittent opening of doors did notsignificantly decrease the number ofcolony-forming units compared with thatmeasured when the doors were left open.
• Implants have been shown to beassociated with a higher rate of positivecultures if left outside their packaging inthe operating room for more than twohours.
RECOMMENDATIONS• GRADE A• Compared with povidone-iodine, chlorhexidinesurgical scrub provides a prolonged reduction inskin contamination with less toxicity and skinirritation• Aqueous surgical hand-rubs are equivalent totraditional surgical scrubs with regard to theirability to reduce bacterial contamination.Surgeons comply with hand-rub protocols betterthan they comply with surgical scrub protocols
• A patient’s temperature, oxygenation, andserum blood glucose level should beoptimized in the perioperative period
GRADE B• The use of iodophor-impregnated surgicaldrapes decreases skin contamination butdoes not appear to reduce infection rates• The use of laminar flow in the operatingroom is associated with decreased ratesof wound infections andwoundcontamination• Hair removal preoperatively should beminimized and, if necessary, performedwith clippers or depilatory products
POST OP DRAINS• the presence of a surgical drain for morethan twenty-four hours was associatedwith a higher likelihood that the woundwould be infected with methicillin-resistantStaphylococcus aureus than withmethicillinsensitive Staphylococcus aureus• The current orthopaedic literature has notshown an advantage to the use of drainsin elective surgery.
WOUND CLOSURE• blood flow was significantly higher on thefirst postoperative day than it was on thefifth day and perfusion in wounds closedwith subcutaneous sutures was greaterthan that in wounds closed with mattresssutures or surgical staples.• Bacterial adherence to braided sutures isthree to ten times higher than adherenceto monofilament sutures
• The proper management of dead space inorthopaedic patients has not been clearlydefined.• subcuticular wound closure withmonofilament sutures minimizes tissueischemia and is associated withdecreased bacterial contamination
RECOMMENDATION• GRADE A:• Use of surgical drains in joint replacementsurgery or closed fracture care isassociated with more blood transfusionsbut not with any increase in the rate ofhematomas, wound infections,reoperations, or thromboembolic diseaseor in the hospital stay, when comparedwith operations performed without a drain
• The rate of surgical site infectionassociated with occlusive dressings islower than that associated withnonocclusive dressings
GRADE B• Surgical dressings may be removed asearly as the first postoperative day withoutany apparent increase in the risk ofinfection• Triple antibiotic ointment increasesepithelialization and has been associatedwith fewer infections in uncomplicatedclean surgical wounds
GRADE I• High-pressure pulsatile lavage removed moredebris than did low-pressure pulsatile or bulb-syringe lavage in an animal model, although thehigher pressure may cause damage to bone andmuscle• Castile soap irrigation appears to remove morebacteria than bacitracin does and may beassociated with fewer wound-healing problemsin an animal model
• There is no apparent difference amongwound closure techniques with regard tothe rate of wound infections• There is insufficient evidence to support orrefute the benefits of closure of deadspace in patients undergoing orthopaedicsurgery