Prevention of Surgical Site Infection After Major Extremity Trauma

Publication Date: March 20, 2022
Last Updated: November 2, 2023

Summary of Recommendations

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)
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Preoperative Antibiotics

Utilization of preoperative antibiotics is suggested to prevent SSI in operative treatment of open fractures. (Moderate)
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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)
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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)
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Perioperative and Postoperative Antibiotics – Local

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

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

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

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

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

In patients undergoing surgery for major extremity trauma, patients should be counseled that:
There may be an increased risk for SSI in patients who smoke or who are diabetic. (Strong)
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  • 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)
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  • 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)
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Administrative Risk Factors

In patients undergoing surgery for major extremity trauma, patients should be counseled that:
There is minimal evidence that race, or socioeconomic status affects risk of SSI. (Moderate)
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There is no significant difference in risk of SSI when being treated as an inpatient or outpatient. (Limited)
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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)
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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)
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Hyperbaric O2

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

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

1. Providers may consider perioperative nasal and skin (full body) decolonization of patients, when possible.

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

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

Overview

Title

Prevention of Surgical Site Infections After Major Extremity Trauma

Authoring Organization

American Academy of Orthopaedic Surgeons

Publication Month/Year

March 20, 2022

Last Updated Month/Year

August 29, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physical therapist, physician, physician assistant, surgical technologist

Scope

Management, Prevention

Keywords

surgical site infection, Surgical Site Infections, major extremity trauma, SSIs

Source Citation

American Academy of Orthopaedic Surgeons. Prevention of Surgical Site Infections After Major Extremity Trauma Evidence-Based Clinical Practice Guideline. www.aaos.org/SSItraumacpg. Published 03/21/22.

Supplemental Methodology Resources

Data Supplement, Data Supplement

Methodology

Number of Source Documents
185
Literature Search Start Date
October 31, 2020
Literature Search End Date
July 31, 2021