POSTOPERATIVE ORTHOPAEDIC WOUND INFECTION

3. ACKNOWLEDGMENT

5. DEFINITION
In 1992, US (CDC) revised its definition of
'wound infection', creating the definition
to prevent
confusion between the infection of a surgical
incision and the infection of a traumatic
wound(Horan et al., 1992).
SSI occurs at the within
of an operation or within of an
operation if a foreign body is implanted as part
of the surgery.

6. a) Superficial incisional
b) Deep incisional

7. (Tsukayama et al., 2003)

9.  Do not penetrate below the lumbar fascia.
 Extend below the lumbar fascia and can present as diskitis,
osteomyelitis, and epidural abscess.

10. INCIDENCE
&
OUTCOME OF
SSIs

11. INCIDENCE AND OUTCOME OF SSIS
most frequently reported nosocomial infection.
of all HAIs are SSIs.
was the highest in orthopedic
surgery.
, the total cost of all SSIs has been
estimated to range between

12. INCIDENCE AND OUTCOME OF SSIS (CONT.)
 Incidence is generally higher.
infection rates from
infection rates from
after decompressive procedures.
after instrumented fusions.

13. SOURCES OF SSIs

14. SOURCES OF SSIS
1. Hematogenous seeding from
1. Air current deposition of a pre-existing infection at a
contaminated particulates. remote site .
1. Direct contact of micro- 2. Bacteria released into the
organisms from contaminated wound when non-sterile body
hands, instruments or sites are entered.
implants.
3. Patient's own skin flora .

15. MICROBIOLOGY
&
PATHOGENESIS

16. MICROBIOLOGY OF SSIs
May cause infection if the natural host
is compromised eg, cutaneous coagulase
I. BACTERIA negative staphylococci.
a) Gram +ve: staphylococci are
the most common cause of
prosthetic joint infections.
b) Gram –ve: eg., pseudomonas
species
c) Anaerobes: eg., bacteriodes &
clostridium species
II. FUNGI

17. RECENT UPDATE IN MICROBIOLOGY OF SSIS
“…(Dowd, Sun et al., 2008) have used
advanced, next-generation, molecular methods
such as bacterial Tag-Encoded FLX Amplicon
Pyrosequencing (bTEFAP) to evaluate the
microbial ecology of SSIs.
In contrast, the results suggest that
anaerobic rod shaped bacteria predominate in
biofilms “

18. PATHOGENESIS OF SSIs
Inoculum of
the bacteria
[ ]
Host Determinants Wound
Defenses Of
Microenvironment
Integrity
Infection
Virulence of
the bacterial
contaminant

19. Biofilms are surrounded by an extracellular matrix that might
physically restrict the diffusion of antimicrobial agents.
Nutrient and oxygen depletion within the biofilm cause some
bacteria to enter a non-growing (i.e. stationary) state in which
they are less susceptible to growth-dependent antimicrobial
killing.

20. DIAGNOSTIC
WORKUP

21. DIAGNOSTIC WORK-UP
Microbiological
studies
Histopathological
Clinical
presentation studies
Biological Imaging
studies studies

22. •Spreading erythema of the skin
around the incision line
• Local pain
• Local oedema
• Heat
• Pyrexia
• Increased exudate /suppuration
• Abscess formation
• Lymphangitis
• Cellulitis
• Loss of function of a limb
• Septacaemia

23.  Obtain
for microbiology and histology.
of sinus tracts or wounds.
 Stop antibiotics
 Synovial fluid cell count – sensitivity:
- Leukocytes >1,700/mm³: 94%
- Neutrophils >65%: 97%
as PCR.

24. in whom the diagnosis of prosthetic
joint–associated infection has not been
established preoperatively.
by an intraoperative frozen section to
look for evidence of acute inflammation.
Varies (≥1 to ≥10 neutrophils /
HPF).

25. Imaging plays an inferior role in early infection.
Useful in delayed and late infections to assess the
extent of infection.
INCLUDES:

26. Inflammatory markers determination
is recommended but is not specific, particularly for early infection,
since these parameters are high for up to two weeks after Surgery.
The diagnostic accuracy for prosthetic joint infection was best for
(Elie et al., 2010).
levels were
but had a (González et al.,
2011).

27. RISK FACTORS
&
RECENT TRENDS IN
PREVENTION OF SSIs

28. RISK FACTORS OF SSIS
1. Age
2. Diabetes Mellitus / Perioperative Hyperglycemia
3. Obesity
4. Tobacco Use
5. Malnutrition
6. Pre-Operative Nares Colonization With Staph Aureus
7. Pre-existing Remote Body Site Infection
8. Compromised Immune System
9. The Presence Of Cirrhosis Or Any Other Debilitating Disease
10. Peri-Operative Transfusions
11. Prolonged Preoperative Hospital Stay
1. Operative Wound Class
2. Patient Skin Preparation In The Operating Room
3. Preoperative Shaving
4. Perioperative Hypoxia
5. Type Of Surgery
6. The Duration Of Surgery
7. Surgical Technique
8. A Postoperative Hematoma
9. Surgical drains
10. Suboptimal Timing Of Antibiotic Prophylaxis
11.Traffic in the Operating Room

29. RECENT TRENDS IN PREVENTION OF SSIs
bathe as normal on the morning of surgery or the day before.
Using chlorhexidine cut the risk for a SSI in half, compared
with washing with 10% povidone-iodine.
performed only when necessary via the use
of electric clippers on the day of surgery.
with CHG and intranasal mupirocin.
wearing non-sterile theatre wear minimize the
risk of SSI.

30. Evaluate patients for pre-existing medical conditions.
Assessment of the patient’s susceptibility and risk factors for
infection.
with antiseptic that contains a combination of CHG
or iodine with alcohol.
alcohol-based rubs is as effective
as aqueous solutions.

31. Choice of antimicrobial agent:
Cephalosporin (cefazolin, cefuroxime)
If β lactam allergy, use clindamycin or vancomycin
Timing of administration:
Start up to 60 min before incision: cefazolin, cefuroxime, clindamycin
Start up to 120 min before incision: vancomycin
Infusion completed 10 min before tourniquet inflation
Dosing:
Cefazolin. 1-2 g (2 g for patient weighing >86 kg)
Cefuroxime, 1.5 g
Vancomycin and clindamycin dosing based on patient mass
Duration:
Single preoperative dose
Redose for prolonged procedure or significant blood loss
discontinue within 24 h after wound closure

32. Forced air warming for patients with a body
temperature <36°C.
Using higher oxygen concentrations
triple the risk of nosocomial infection compared with no transfusion.
should be maintained for the first 48 hours after surgery.
By betadine, Antibiotics & Detergents
Use pulsatile lavage

33.  laminar airflow
 Temperature should be maintained between (18 to 25 ºC) and
humidity between (40 to 60%).
 a second pair of surgical gloves provides a protective barrier to
both the patient and surgeon.
should be resistant to
tears, punctures, and abrasions.

34. The sterile dressing should remain in place for 24-48 hours
postoperatively.
Silver-containing hydrofiber® (SCH) dressing (AQUACEL®
silver [AG] dressing provides an excellent choice because:

35. INPATIENT SSI
SURVEILLANCE
direct observation for SSI
by a surgeon or a trained nurse
combination of the
following: review of microbiology
reports, surgeon and/or patient surveys, and
screening for readmission of surgical patients.
Follow-up phone calls to patients
POST-DISHARGE
SURVEILLANCE
Outpatient culture reports
Outpatient reports of antibiotic usage data
Readmission data to hospital or to another
hospital

36. TREATMENT OF
SSIs

38. I. GENERAL TREATMENT OF SSIs
Helps:
To promote normal wound healing.
Identify risk factors as obesity, DM.
Identify early signs of infection.

39. Superficial incisional SSI can usually be treated
without debridement, with oral antibiotics.
Suspected deep or organ/space SSI, fever
(temperature>38.5◦C), or tachycardia (heart rate,
110 beats/min) generally require antibiotics in
addition to opening of the suture line.
Most surgical wounds that are re-opened are left to
heal by secondary intention.

40. :
Not Indicated:
For uncomplicated SSIs
Indicated:
 If there is systemic evidence of
Toxicity or cellulitis that extends
>2 cm beyond the incision.
The Choice Of Antibiotic:
 Is defined by the operation
performed through the incision
and the likely infecting organism.

41. , the reference standard MRSA treatment.
, twice as active as vancomycin against S. aureus.
are recommended for the
outpatient treatment of non severe SSI.
are recommended in outpatients with
moderately severe infections and for hospitalised patients with
severe SSIs.
are the most active agents
against Gram-positive bacteria across Europe.

42. infection.
its recurrence.
mechanical joint function.

44. the germ.
wound closure.
spinal/vertebral
stability.
union of any grafts.

45. Extremely superficial infections such as small
abscesses on the suture can be treated locally.
Most superficial and deep infections require
aggressive excision of tissue associated with initial
intravenous antibiotic therapy.
The duration of initial parenteral antibiotic
treatment is usually 15 days. Then propose oral
antibiotics.
Some recommend removing all bone graft and spinal
implants, whereas others support leaving well-fixed
posterior instrumentation (particularly titanium) and bone
grafts in place, even in the face of active infection.

46. of the fracture.
of chronic osteomyelitis.

47.  If the implant is stable, debridement with retention
of the device combined with long-term antibiotic
treatment.
 If resistant or difficult-to-treat microorganisms
are causing the infection complete hardware removal
and external fixation is preferable.
 Duration is 3 months in cases of device retention and
6 weeks after removal of the infected fixation device.
IV treatment should be administered for the first 2−4
wks, followed by oral therapy.