American Academy of Orthopedic Surgeon (AAOS):

American Academy of Orthopedic Surgeon (AAOS) developed 14 strong and moderate-strength recommendations to decrease surgical site infections after major extremity trauma

Summary of Recommendations

1.      Initial Antibiotics

Early delivery of antibiotics is suggested to lower the risk of deep infection in the setting of open fracture in major extremity trauma. (Moderate)

2.      Preoperative Antibiotics

Utilization of preoperative antibiotics is suggested to prevent Surgical Site Infection (SSI) in operative treatment of open fractures. (Moderate)

3.      Surgery Timing

It is suggested that patients with open fractures are brought to the OR for debridement and irrigation as soon as reasonable, and ideally before 24 hours post injury. (Moderate)

4.      Perioperative and Postoperative Antibiotics - Systemic

In patients with major extremity trauma undergoing surgery, it is recommended that antibiotic prophylaxis with systemic cefazolin or clindamycin be administered, except for Type III (and possibly Type II) open fractures, for which additional Gram-negative coverage is preferred. (Strong)

5.      Perioperative and Postoperative Antibiotics – Local

In patients with major extremity trauma undergoing surgery, local antibiotic prophylactic strategies, such as vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails, may be beneficial. (Moderate)

6.      Initial Wound Management - Irrigation

Irrigation with saline (without additives) is recommended for management of open wounds in major extremity trauma. (Strong)

7.      Initial Wound Management - Fixation

Definitive fixation of fractures at initial debridement and primary closure of wounds in selected patients may be considered when appropriate, however no favored treatment was observed. Temporizing external fixation remains a viable option for the treatment of open fractures in major extremity trauma. (Strong)

8.      Wound Coverage

Wound coverage fewer than 7 days from injury date is suggested. (Moderate)

9.      Negative Pressure Wound Therapy – Open and Closed Fractures

After closed fracture fixation, negative pressure wound therapy may mitigate the risk of revision surgery or SSIs; however, after open fracture fixation, negative pressure wound therapy does not appear to offer an advantage when compared to sealed dressings as it does not decrease wound complications or amputations. (Strong)

10.   Open Wound Closure

Closing an open wound when it is feasible, without any gross contamination is recommended. (Strong)

11.   Silver Coated Dressings

Silver coated dressings are not suggested to improve outcomes or decrease pin site infections. (Moderate)

In patients undergoing surgery for major extremity trauma, patients should be counseled that:

12.   Modifiable Risk Factors

There may be an increased risk for SSI in patients who smoke or who are diabetic. (Strong)

• There may be an increased risk for SSI in obese patients
• Significant alcohol use (>14 units per week) increases the risk of infection postoperatively
• High flow perioperative FIO2 has not been shown to alter the risk of postoperative infection(Moderate)

• Low albumin (<36g/L) increases the risk of infection postoperatively
• Elevated postoperative glucose levels (>125 mg/dL) increase the risk for infection
• Preoperative transfusion, intraoperative evaluation by a vascular service in patients with grade 3a, 3b open fractures with well perfused limbs, and preoperative MRSA positivity has not been shown to alter the risk of postoperative infection (Limited)

In patients undergoing surgery for major extremity trauma, patients should be counseled that:

14.   Negative Pressure Wound Therapy - High Risk Surgical Incisions

It is suggested to use an incisional negative pressure wound therapy for high- risk surgical incisions (e.g., pilon, plateau, or calcaneus fractures) to reduce the risk of deep surgical site infection. (Limited)

15.   Orthoplastic Team

Implementation of an orthoplastic team may decrease length of stay, deep infection, and additional operations to bone, and also may help improve time to wound healing and time to union. (Limited)

16.   Hyperbaric O2

In patients with open fracture, hyperbaric O2 may not benefit patient outcomes. (Limited)

Preoperative Skin Preparation

In the absence of reliable evidence, it is the opinion of the workgroup that:

17.   Perioperative nasal and skin (full body) decolonization:

Providers may consider perioperative nasal and skin (full body) decolonization of patients, when possible. S. aureus nasal carriage is associated with subsequent infection in surgical patients.

In the WHO evidence-based recommendations for the prevention of SSIs, the panel made a conditional recommendation that patients undergoing orthopaedic surgery who are known nasal carriers of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of chlorhexidine gluconate body wash

Preoperative showering or bathing:

Patients should shower or bathe (full body) with soap (anti-microbial or non-anti-microbial) or an antiseptic agent before surgery, when possible.

Preoperative whole-body bathing is a good clinical practice to ensure that the skin is clean before surgery and to decrease the bacterial burden. Either a plain or antiseptic soap can be used for preoperative bathing

Surgical skin preparation:

Surgical skin preparation should be performed with an alcohol-based antiseptic agent, unless contraindicated. (Consensus).