23 Surgical Site Infection
Prevention
Mitchell C. Weiser | Calin S. Moucha
INTRODUCTION
Surgical site infection (SSI) is one of the most common and
devastating complications of orthopaedic surgical procedures.
In its most recent estimate, the Centers for Disease Control
and Prevention (CDC) reported that SSIs accounted for
36.4% of all healthcare-associated infections, with orthopaedic
surgery responsible for 23.7% of reported SSIs.1 More than
365,000 SSIs occur annually in the United States, resulting in
estimated direct and indirect medical costs approaching $10
billion.1,2 In 2007 there were more than 45 million procedures
in the United States, of which more than 450,000 included
open reduction and internal xation.3
Although advances in infection prevention have occurred
over recent years, SSIs remain a substantial cause of morbidity
and mortality. Patients with SSIs are 60% more likely to spend
time in an intensive care unit, twice as likely to die, and ve
times more likely to be readmitted compared with patients
without an SSI.4 In surgical patients with an SSI who died,
89% of the deaths were attributable to the infection.5 These
statistics translate not only into signicant losses for the
individual patient but also a dramatic burden on societal
healthcare costs as a whole.
The ve most common pathogens involved in SSIs between
2011 and 2014, in descending order of frequency, were
Staphylococcus aureus (20.7%), Escherichia coli (13.7%),
coagulase-negative staphylococci (7.9%), Enterococcus faecalis
(7.5%), and Pseudomonas aeruginosa (5.7%).1 More recently
there has also been an increase in infections related to
antimicrobial-resistant pathogens such as methicillin-resistant
S. aureus (MRSA) and vancomycin-resistant enterococci, both
of which colonize the skin and are spread by direct contact.6 In
the United States it has been estimated that approximately
80,000 invasive MRSA infections occurred in 2011 and that
60% of these were healthcare associated.7 The death rate from
MRSA is 2.5 times greater than from nonresistant S. aureus, and
more than 11,000 MRSA deaths were documented in 2011.7–9
In the United States prevention and treatment of these
infections have become national priorities. The Healthcare
Infection Control Practices Advisory Committee (HICPAC)
is a federal advisory committee that consists of 14 external
infection control experts. The HICPAC works together
with the CDC and the Secretary of the Department of Health
and Human Services to formulate best practices for healthcare-
associated infection prevention, control, and surveillance.
The CDC’s National Nosocomial Infections Surveillance
System (NNIS), established in 1970, monitors nosocomial
infection trends.
660
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In an effort to make evidence-based recommendations on
infection prevention, the CDC published the “Guideline for
Prevention of Surgical Site Infection, 1999.”6,10 In 2002 the
CDC collaborated with the Centers for Medicare and Medicaid
Services (CMS) to implement the Surgical Site Infection
Project. The goal of the project was to decrease mortality
and morbidity associated with SSIs by promoting appropriate
prophylactic antibiotic choice and timing. Effective July 1,
2006, The Joint Commission expanded the Surgical Site
Infection Project to the Surgical Care Improvement Project
(SCIP). SCIP is a partnership of many organizations dedicated
to improving surgical care. The American Academy of
Orthopaedic Surgeons (AAOS) is one of more than 30
organizations represented. The goal of SCIP was to reduce
the incidence of surgical complications nationally by 25%
by 2010. Some of the SCIP target areas pertinent to ortho-
paedic surgery are shown in Box 23.1.11
DEFINING SURGICAL SITE INFECTIONS
The NNIS has provided standardized surveillance criteria
for dening SSIs (Fig. 23.1 and Box 23.2). These deni-
tions, applied consistently by surveillance personnel, have
become a national standard. SSIs are classied as super-
cial if they involve only the skin and subcutaneous tissue
Skin
Superficial
incisional
SSI
Subcutaneous
tissue
Deep soft tissue Deep incisional
(fascia and muscle) SSI
Organ/space
Organ/space
SSI
Fig. 23.1 Cross section of the abdominal wall. Wounds are classied
as supercial incisional, deep incisional, and organ/space infections.
SSI, Surgical site infection. (From Mangram AJ, Horan TC, Pearson ML,
et al. Guideline for prevention of surgical site infection, 1999. Centers for
Disease Control and Prevention [CDC] Hospital Infection Control Practices
Advisory Committee. Am J Infect Control. 1999;27[2]:97–132.)

Box 23.1 Surgical Care Improvement Project (SCIP) Milestones: SCIP Identier Process or
Outcome Measures
Infection
SCIP INF 1: Prophylactic antibiotic received within 1 hour before
surgical incision
SCIP INF 2: Prophylactic antibiotic selection for surgical patients
SCIP INF 3: Prophylactic antibiotics discontinued within 24 hours
after surgery end time (48 hours for cardiac patients)
SCIP INF 4: Cardiac surgery patients with controlled 6 a.m.
postoperative serum glucose measurement
SCIP INF 5a: Postoperative surgical site infection diagnosed during
index hospitalization
SCIP INF 6: Surgery patients with appropriate hair removal
Venous Thromboembolism
SCIP VTE 1: Surgery patients with recommended VTE prophylaxis
ordered
DVT, Deep vein thrombosis; INF, infection; PE, pulmonary embolism; VTE, venous thromboembolism.
From Fry DE. Surgical site infections and the Surgical Care Improvement Project (SCIP): evolution of National Quality Measures. Surg Infect.
2008;9(6):579–584.
Box 23.2 Criteria for Dening a Surgical Site Infection (SSI)
Supercial Incisional SSI
Infection occurs within 30 days after the operation and infection
involves only skin or subcutaneous tissue of the incision and at
least one of the following:
1. Purulent drainage, with or without laboratory conrmation, from
the supercial incision
2. Organisms isolated from an aseptically obtained culture of uid
or tissue from the supercial incision
3. At least one of the following signs or symptoms of infection:
pain or tenderness, localized swelling, redness, or heat and
supercial incision is deliberately opened by surgeon unless
the incision is culture negative
4. Diagnosis of supercial incisional SSI by the surgeon or attending
physician
Do not report the following conditions as SSI:
1. Stitch abscess (minimal inammation and discharge conned
to the points of suture penetration)
2. Infection of an episiotomy or newborn circumcision site
3. Infected burn wound
4. Incisional SSI that extends into the fascial and muscle layers
(see deep incisional SSI)
Note: Specic criteria are used for identifying infected episiotomy
and circumcision sites and burn wounds.
Deep Incisional SSI
Infection occurs within 30 days after the operation if no implanta
is left in place or within 1 year if the implant is in place and the
infection appears to be related to the operation and infection
involves deep soft tissues (e.g., fascial and muscle layers) of the
incision and at least one of the following:
1. Purulent drainage from the deep incision but not from the
organ/space component of the surgical site
a
National Nosocomial Infection Surveillance denition: a non–human-derived implantable foreign body (e.g., prosthetic heart valve, nonhuman vascular
graft, mechanical heart, or hip prosthesis) that is permanently placed in a patient during surgery.
b
If the area around a stab wound becomes infected, it is not an SSI. It is considered a skin or soft tissue infection, depending on its depth.
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CHAPTER 23 — SuRgiCAl SiTE infECTion PREvEnTion 661
SCIP VTE 2: Surgery patients who received appropriate VTE
prophylaxis within 24 hours before surgery to 24 hours after
surgery
SCIP VTE 3a: Intraoperative or postoperative PE diagnosed during
index hospitalization or within 30 days of surgery
SCIP VTE 4a: Intraoperative or postoperative DVT diagnosed during
index hospitalization or within 30 days of surgery
Global
SCIP Global 1: Death within 30 days of surgery
SCIP Global 2: Readmission within 30 days of surgery
2. A deep incision spontaneously dehisces or is deliberately opened
by a surgeon when the patient has at least one of the following
signs or symptoms: fever (>38°C), localized pain, or tenderness
unless the site is culture negative
3. An abscess or other evidence of infection involving the deep
incision is found on direct examination, during reoperation, or
by histopathologic or radiologic examination
4. Diagnosis of a deep incisional SSI by a surgeon or attending
physician
Notes
1. Report infection that involves both supercial and deep incision
sites as deep incisional SSI
2. Report an organ/space SSI that drains through the incision as
a deep incisional SSI
Organ/Space SSI
Infection occurs within 30 days after the operation if no implanta
is left in place or within 1 year if the implant is in place and the
infection appears to be related to the operation and infection
involves any part of the anatomy (e.g., organs or spaces) other
than the incision, which was opened or manipulated during an
operation and at least one of the following:
1. Purulent drainage from a drain that is placed through a stab
woundb into the organ/space
2. Organisms isolated from an aseptically obtained culture of uid
or tissue in the organ/space
3. An abscess or other evidence of infection involving the organ/
space that is found on direct examination, during reoperation,
or by histopathologic or radiologic examination
4. Diagnosis of an organ/space SSI by a surgeon or attending
physician
662 SECTion onE — gEnERAl PRinCiPlES
and deep if the infection is within the fascia or muscle.
Organ/space SSIs involve any part of the anatomy other
than incised body wall layers that were manipulated during
surgery. Septic arthritis, septic bursitis, diskitis, epidural
abscess, and osteomyelitis are considered organ/space
SSIs. Infection occurs within 30 days after the procedure
if no implant is left in place or within 1 year if an implant
is in place and the infection appears to be related to the
operation.
It is important to note that other organizations have also
formulated evidence-based denitions of orthopaedic infec-
tions. The AAOS12 and the Musculoskeletal Infection Society13
have specic recommendations and denitions for diagnosing
periprosthetic joint infections (PJIs) (Box 23.3). Although
these denitions are not currently used by government
agencies, the American Joint Replacement Registry (AJRR)
currently endorses these denitions for the purposes of
reporting periprosthetic infections after total hip and knee
arthroplasty.14
PREOPERATIVE INTERVENTIONS
Infection control is best integrated into a clinical practice
using an outside-to-inside methodology.15 The AAOS Patient
Safety Committee has identied a variety of modiable risk
factors for SSI (Fig. 23.2).16,17 Certainly, not all of these risk
factors can be applied to the acute trauma setting. Many
orthopaedic patients, however, are unhealthy hosts, and
optimizing these patients as best as possible before surgery
Local or
remote
orthopaedic
infection Rheumatoid
arthritis
Poor oral
health
MODIFIABLE
RISK FACTORS
FOR INFECTIONS
Urinary tract
infections
Obesity
Patients at Preoperative
risk for
Methicillin-resistant anticipated
Staphylococcus postoperative
aureus anemia
Box 23.3 Musculoskeletal Infection
Society Denition of
Periprosthetic Joint Infection
Based on the proposed criteria, denite periprosthetic joint
infection exists when:
1. There is a sinus tract communicating with the prosthesis;
or
2. A pathogen is isolated by culture from at least two separate
tissue or uid samples obtained from the affected prosthetic
joint; or
3. Foura of the following six criteria exist:
a. Elevated serum ESR and serum CRP concentration
b. Elevated synovial leukocyte count
c. Elevated synovial neutrophil percentage (PMN%)
d. Presence of purulence in the affected joint
e. Isolation of a microorganism in one culture of periprosthetic
tissue or uid
f. Greater than ve neutrophils per high-power eld in ve
high-power elds observed from histologic analysis of
periprosthetic tissue at >400× magnication.
a
A periprosthetic joint infection may be present if fewer than four of
these criteria are met.
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; PMN,
polymorphonuclear neutrophils.
Adapted from Parvizi J, Zmistowski B, Berbari EF, et al. New denition
for periprosthetic joint infection: from the Workgroup of the
Musculoskeletal Infection Society. Clin Orthop Rel Res. 2011;469(11):
2992–2994.
Human
immunodeficiency
virus
Diabetes
Malnutrition
Smoking
Fig. 23.2 Modiable risk factors for surgical
and site infection. (Reprinted from: The American
Academy of Orthopaedic Surgeons Patient
Safety Committee, Evans RP. Surgical site
infection prevention and control: an emerging
paradigm. J Bone Joint Surg Am. 2009;91
[Suppl 6]:2–9.)
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may be the most important and tangible aspect of SSI
prevention. Despite increased attention and awareness
regarding the inuence of modiable risk factors on the
rate of SSI over the course of the past decade,18–21 direct
scientic evidence showing that risk factor modication alone
will lead to a lower SSI rate is still lacking, as successful
intervention is often multifactorial in nature.22
SMOKING
Smoking is a well-known risk factor for multiple surgical
complications, including infection.20,23–25 Tobacco products
cause microvascular vasoconstriction via the effects of nicotine
on the sympathetic nervous system. Tissue hypoxia is caused
by carbon monoxide binding to hemoglobin and creating
carboxyhemoglobin.26–28 Additionally, cigarette smoke has
been shown to impair the immune system by diminishing
the activity of T cells,29 as well as interfere with collagen
synthesis, leading to impaired wound healing.30 A prospective
study of 3908 patients undergoing orthopaedic surgery with
implanted materials identied a signicant association
between smoking and organ/space SSI.31 Similar ndings
were identied in a large retrospective study of 78,191 patients
in the American College of Surgeons National Surgical Quality
Improvement Program (ACS-NSQIP) database who underwent
primary total hip or knee arthroplasty.25 Smoking intervention
programs, even when instituted as briey as 4 weeks before
surgery, can diminish the risk of complications.32–35 These
preprocedure interventions are often not feasible in nonelec-
tive surgery, such as orthopaedic trauma. However, there is
still value in initiating a smoking cessation intervention after
nonelective surgery, as a prospective, randomized, controlled
trial demonstrated a reduction in postoperative complications
with the initiation of a postoperative smoking cessation
program in tobacco users with operative fractures.36
OBESITY
Obesity, dened as a body mass index of 30 kg/m2 or greater,
is a known risk factor for postoperative infections after
undergoing orthopaedic surgery.37–39 The pathogenesis by
which many obese patients go on to have a postoperative
infection is multifactorial. The diet many of these patients
follow is devoid of essential nutrients. Surgical time is often
longer for these patients,39 and hematoma or seroma forma-
tion leading to prolonged drainage is more common.40 The
subcutaneous layer in these patients is often poorly vascular-
ized, and they require a signicantly greater fraction of
inspired oxygen (FiO2) to reach an arterial oxygen tension
of 150 mm Hg.41 Meticulous treatment of soft tissues and
expedited surgeries by experienced surgeons should be
considered whenever possible. Obese patients should have
properly dosed prophylactic antibiotics42 and nutritional
counseling perioperatively. Last, these patients need to be
counseled never to try to lose weight while healing their
surgical wounds because this may lead to a catabolic state.
RHEUMATOID ARTHRITIS
Patients with rheumatoid arthritis have an increased risk of
infection after orthopaedic procedures such as joint
replacement. Many of these patients are treated with complex
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CHAPTER 23 — SuRgiCAl SiTE infECTion PREvEnTion 663
drug regimens that have an effect on wound healing.
Antiinammatory medications should be held perioperatively
both because of wound healing complications that can lead
to infection and their potential effects on wound healing.43
Despite corticosteroids having been shown to increase infec-
tion rates and affect wound healing,44,45 these medications
should be continued in the perioperative period. Although
the use of stress-dose steroids remains controversial, a recent
joint recommendation statement from the American College
of Rheumatology and the American Association of Hip and
Knee Surgeons suggests that patients with daily doses of
prednisone less than 20 mg/day undergoing primary hip
and knee arthroplasty do not need stress-dose steroids before
surgery, and should be given their usual prednisone dose
instead.46 However, each patient should be dealt with individu-
ally, keeping in mind the chronicity and dose of steroid
usage, anticipated stress level of the surgery, and the presence
of other risk factors for infection.43,47 Nonbiologic disease-
modifying antirheumatic drugs, such as methotrexate or
sulfasalazine, should not be discontinued perioperatively
except in patients with renal insufciency, poorly controlled
diabetes, lung or liver disease, or a history of alcohol
abuse.43,46–48 Biologic agents have been associated with an
increased risk of postoperative infections,49,50 and it is recom-
mended that they be held during the perioperative period
and not restarted until the wound demonstrates signs of
healing, typically 2 weeks after surgery.46 Perioperative
consultation with a rheumatologist who has experience with
these medications is recommended.
HUMAN IMMUNODEFICIENCY VIRUS
The number of patients infected with human immunode-
ciency virus (HIV) who are undergoing orthopaedic proce-
dures is on the rise.51 Some studies, many in arthroplasty
patients, done on these patients have shown a higher SSI
risk, but others have not.52–58 A recent study of orthopaedic
trauma patients who were HIV positive revealed that those
patients with CD4 counts less than 300 cells/µL were at higher
risk of developing a postoperative infection than those without
HIV.59 Routine screening of orthopaedic patients for
immunodeciencies has not been shown to be cost effective
and should be reserved for patients with other risk factors.60
One study suggested that to diminish the risk of SSI in this
patient population, we should administer prolonged
prophylactic antibiotic therapy and antiretroviral therapy,61
and a recent systematic review suggested that highly active
antiretroviral therapy (HAART) helps reduce the risk of
periprosthetic infection in HIV patients undergoing total
joint arthroplasty.58 Eliminating or modifying other risk factors
(injection drug use, smoking, serum glucose level, and
prolonged wound drainage) and optimizing psychosocial
issues are of utmost importance in these patients.52
STAPHYLOCOCCUS AUREUS SCREENING AND
DECOLONIZATION
S. aureus continues to be one of the most common organisms
in orthopaedic SSI.1,62 Nasal carriers of S. aureus are two to
nine times more likely to acquire SSIs than noncarriers,63,64
and 80% to 85% of the time S. aureus wound isolates in
patients with SSIs match those from their nares.65,66 Reductions
664 SECTion onE — gEnERAl PRinCiPlES
in postoperative rates of SSIs can be achieved with prescreening
programs for S. aureus carrier status in patients undergoing
elective orthopaedic surgery.67 Several reviews have conrmed
the value of screening and decolonization in patients
undergoing orthopaedic surgery.68–70 Screening can be
accomplished with either nasal swab culture or polymerase
chain reaction (PCR) techniques.70 PCR screening produces
a much faster result than culture swabs, on the order of
hours as opposed to days, which may be valuable for trauma
patients who are hospitalized and scheduled to undergo
urgent/emergent nonelective surgery.70 Older studies have
suggested that prophylactic treatment of MRSA/MSSA carriers
with mupirocin ointment applied to the nares and
chlorhexidine baths may reduce infection risk in orthopaedic
surgery.67,71,72 Although this regimen has been successful, it
is generally recommended to begin 5 days before surgery
and has been associated with poor patient compliance.73
Commercially available povidone-iodine swabs have been
shown to be as effective as mupirocin at nasal decolonization
of MRSA/MSSA in patients undergoing total joint arthroplasty
and spine surgery, and may be a more convenient option in
trauma surgery patients because they only require one-time
administration 1 hour before surgery.74 S. aureus screening
and decolonization protocols should be repeated before any
readmission, regardless of prior colonization status, as
decolonization may not be durable over the long term.75
Risk factors for persistent MRSA carriage include previous
MRSA infection; being a healthcare worker, nursing home
patient, or prisoner; and being in contact with a patient who
has MRSA colonization. Patients found to be carriers of MRSA
should be considered candidates for vancomycin prophylactic
antibiotics in place of (or possibly in addition to) a cepha-
losporin, although strict guidelines cannot currently be
established. Hospitals with antibiograms showing a high
percentage of resistant bacteria should also consider altering
their prophylactic prophylaxis regimen appropriately.76
DIABETES MELLITUS
Diabetes and hyperglycemia have been known risk factors
for orthopaedic SSI for some time. Although the pathologic
effects of diabetes on surgical hosts are clearly detrimental,
the acute effects of perioperative hyperglycemia are both
more detrimental and more readily addressed.77 Several studies
have shown an association between diabetes and postoperative
infection in patients undergoing hip and knee arthroplasty;
however, it is still controversial whether hemoglobin A1c or
perioperative serum glucose is the better marker for predicting
postoperative infection risk.78–81 It is the authors’ opinion
that perioperative hyperglycemia is likely more important
and more prevalent than the diagnosis of diabetes itself. It
has been dened in many studies as blood glucose levels
above 200 mg/dL at the time of surgery. In the trauma setting,
elevated blood glucose level occurs in up to 50% of patients
in the intensive care ward,82 and the etiology of this stress-
induced hyperglycemia is multifactorial.83,84
The pathogenesis of hyperglycemia leading to infection
has been well described. Chemotaxis, phagocytosis, and
oxidative bacterial killing are all diminished by high serum
glucose levels.85–87 Hyperglycemia leads to glycosylation of
complement proteins and immunoglobulins resulting in
overall host immunosuppression.88 Multiple studies have
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shown the advantage of tight glycemic control in critically
ill patients.89,90 Cardiac surgery studies have conrmed that
sternal wound infections are more likely to occur in hyper-
glycemic patients.91 In these patients, implementation of
continuous insulin infusion protocols reduces the rates of
deep sternal wound infections.92 Several studies in orthopaedic
spine surgery,38 joint replacement surgery,81,93 ankle fracture
surgery,94 and proximal humerus fracture surgery95 support
the role of perioperative glycemic control in patients undergo-
ing orthopaedic surgery. Even though studies supporting
interventions at multiple points of care are still needed, tight
perioperative glucose control is clearly critical in orthopaedic
patients.96
MALNUTRITION
Malnutrition is a known risk factor after orthopaedic proce-
dures. Screening should be done in patients at risk of malnutri-
tion, such as elderly adults and those with gastrointestinal
diseases, renal failure, alcoholism, cancer, or any chronic
disease.97–99 Total lymphocyte count of less than 1500/mm3
(1.5 × 109/L), serum albumin level less than 3.5 g/dL, or
transferrin level of less than 226 mg/dL should prompt
caretakers to initiate consultations with an endocrine or
nutritional expert.
ANEMIA
Postoperative anemia treated with allogeneic blood transfusion
is a risk factor for SSI in patients undergoing arthroplasty
procedures.100,101 It is likely that many patients receive
unnecessary transfusions. A study enrolled 2016 patients who
were 50 years of age or older who had either a history of or
risk factors for cardiovascular disease and whose hemoglobin
levels were below 10 g/dL after hip fracture surgery.102 The
investigators randomly assigned patients to a liberal transfusion
strategy (a hemoglobin threshold of 10 g/dL) or a restrictive
transfusion strategy (symptoms of anemia or at physician
discretion for a hemoglobin level of <8 g/dL). A liberal
transfusion strategy, compared with a restrictive strategy, did
not reduce rates of death or inability to walk independently
on 60-day follow-up or reduce in-hospital morbidity. Postopera-
tive risk of transfusion can be diminished with perioperative
interventions. Epoetin alfa directly increases preoperative
red blood cell mass, hemoglobin concentration, and hema-
tocrit levels. It has been shown to be useful for lowering
transfusion requirements in total joint replacement
procedures,103 but not in pediatric neuromuscular scoliosis
patients.104 A recent pooled observational analysis of very
short-term perioperative administration of intravenous (IV)
iron in patients undergoing major orthopaedic surgery has
renewed interest in this important modality.105 Tranexamic
acid, an antibrinolytic included on the World Health
Organization’s list of essential medicines, has been shown
to be a useful adjuvant in the prevention of postoperative
allogeneic blood transfusions in spinal,106 joint replacement,107
and hip fracture108,109 surgeries.
DENTAL HEALTH
Poor oral health, urinary tract infections, and local or remote
orthopaedic infections have also been identied by the AAOS

as being modiable risk factors for SSI. Whenever possible,
decayed teeth, untreated dental abscesses, advanced gingivitis,
and periodontitis should be taken care of before surgical
intervention; this practice is commonly advocated in cardiac
surgery.110,111 Urinary tract infections and a subsequent delay
in surgical intervention should be handled based on the
type of symptoms (obstructive vs. irritative) and bacterial
colony count.112,113 Although it is not the topic of this chapter
to discuss the diagnosis of infection for all types of orthopaedic
procedures, one should consider at the very least obtaining
a C-reactive protein level and an erythrocyte sedimentation
rate in all patients undergoing conversion of previous surgery
to total joint replacement and in all patients undergoing
nonunion surgery.
It may not always be possible to optimize patients completely
in the trauma setting. However, there is almost always some-
thing that can be addressed perioperatively to improve the
surgical host and diminish the risk of SSI.
PROPHYLACTIC ANTIBIOTICS
All surgical wounds are at risk of bacterial contamination.
Normal skin transmits aerobic gram-positive cocci, and body
orices contaminate wounds with enteric bacteria.
Prophylactic antibiotics do not sterilize the wound; rather,
their administration allows the host to ght off inevitable
bacterial contamination more effectively.6 The ideal antibiotic
should be active against the most common pathogens in
wounds, have minimal side effects, achieve adequate con-
centrations in the tissue during the entire time that the wound
is open, and carry the smallest impact possible on the patient’s
normal bacterial ora. Poor antibiotic selection and timing
will lead to ineffective prophylaxis.114
Studies on the topic of antibiotic prophylaxis are mostly
seen in the eld of joint replacement surgery115–118 and closed
fracture xation.119–122 The Dutch Trauma Trial,123 a
prospective, randomized, double-blind, placebo-controlled
study, looked at 2195 closed fractures. Patients received either
preoperative ceftriaxone or placebo. The infection rate was
3.6% in the antibiotic group and 8.3% in the placebo group.
A more recent meta-analysis124 supports these ndings. In
lower extremity arthroplasty cases and in closed fracture
procedures, administration of prophylactic antibiotics is the
standard of care in the majority of cases. Routine use of
prophylactic antibiotics in spine surgery has also been
supported by multiple studies.117,125–128
Fields such as foot and ankle surgery129,130 and nontraumatic
upper extremity surgery131–133 tend not to advocate routine
use of prophylactic antibiotics, although studies are limited.
It has been the observation of the authors that most surgeons
appear to give prophylactic antibiotics for ankle and hand
arthroplasty procedures, as well as for extensive reconstructive
procedures in any eld.
TIMING OF ADMINISTRATION
Burke,134 building on the work of Lister,135 investigated the
effects of parenteral antibiotics on surgical incisions con-
taminated with S. aureus. This seminal study discovered the
importance of adequate tissue levels of antibiotics before
incision. Several years later, Stone and colleagues136 critically
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CHAPTER 23 — SuRgiCAl SiTE infECTion PREvEnTion 665
evaluated 400 nonorthopaedic patients and clearly showed
a reduction of infection rates with preoperative antibiotics.
The lowest rate of SSI has been observed with antibiotics
given briey before incision. Classen and colleagues137
prospectively studied the timing of antibiotic prophylaxis in
2847 patients and found that those receiving antibiotics during
the 2 hours before the incision had the lowest risk of wound
infection. Cephalosporin and clindamycin infusions should
begin within 60 minutes of incision and be completed just
before the incision. Vancomycin infusion should begin 1 to
2 hours before the incision because fast administration may
result in “red man” syndrome, a condition characterized by
hypotension and a rash. A recent meta-analysis by de Jonge
and colleagues138 of 54,552 patients undergoing various
surgical procedures found that the risk of SSI doubled if
perioperative antibiotics were administered after surgical
incision and was ve times higher if administered more than
120 minutes before incision, but that there was no statistically
signicant difference in SSI rates if the antibiotics were
administered within 120 minutes before surgical incision. It
should be noted that tourniquet usage affects tissue concentra-
tions of antibiotics, and appropriate timing of antibiotic
administration should be adjusted accordingly. Johnson139
studied cefuroxime concentration in bone and subcutaneous
fat during knee arthroplasty. Patients were randomized to
receive the antibiotics 5, 10, 15, and 20 minutes before
tourniquet ination. Bone concentrations were above the
minimum inhibitory concentration (MIC) for S. aureus in
all groups. Subcutaneous fat levels were lower than MIC for
S. aureus in 86% of patients who received antibiotics at 5
minutes before tourniquet ination. The author concluded
that at least 10 minutes is needed between administration
of antibiotics and tourniquet ination to achieve adequate
tissue levels of cefuroxime. Two other studies support these
ndings.140,141 Investigations in the foot and ankle literature
suggest that administration of antibiotics after tourniquet
ination may not be detrimental.142,143
Even though there is enough evidence showing that
preoperative antibiotics should be administered before inci-
sion, reports show that this still does not happen routinely.144,145
Although educating team members, instituting organized
perioperative checklists, and providing feedback to surgeons
has raised compliance in some countries,146 more work remains
to be done.
ANTIMICROBIAL CHOICES
Perioperative antibiotics should be directed against the most
common organisms that might contaminate the surgical
wound. In the case of most orthopaedic surgeries, the most
common offending organisms that lead to SSIs are gram-
positive cocci species that colonize skin.62 Therefore rst-
generation cephalosporins, which are effective against these
organisms, are commonly employed as a prophylactic antibiotic
in orthopaedic surgery. Second- and third-generation cepha-
losporins have a broader spectrum than the rst generation,
but are not as effective against gram-positive bacteria. Cunha
and colleagues147 investigated several antibiotics during total
hip replacement and showed that 25 to 40 minutes after
injection of cefazolin, a rst-generation cephalosporin, the
peak bone level was 60 times the MIC of penicillin-resistant
staphylococci. The half-lives of cephalosporins are sufciently
666 SECTion onE — gEnERAl PRinCiPlES
long enough that adequate tissue levels remain throughout
most orthopaedic procedures. The cost of these agents is
relatively low, as is the risk of adverse effects. As such, they
continue to be widely used and recommended for prophylaxis
in orthopaedic surgery.148 Although patients sometimes have
concerns about allergic reactions, it is important to delineate
whether or not these are true allergic reactions. The incidence
of adverse reactions to cephalosporins in patients with
reported penicillin allergy is rare. If skin testing or history
points to a true allergy (e.g., hypotension, bronchospasm,
pruritus, urticaria), other agents, such as vancomycin, should
be considered. Penicillin allergy testing can decrease
prophylactic vancomycin use in patients treated with elective
orthopaedic surgery.149
Clindamycin and vancomycin are alternative agents that
can be used as prophylaxis when cephalosporins are contra-
indicated. Compared with cephalosporins, bone penetration
of vancomycin appears to be inferior, but that of clindamycin
is comparable. Clindamycin150,151 and vancomycin152 both
exceed the MIC of gram-positive organisms that cause
orthopaedic infections. However, increased use of vancomycin
leads to increased resistance and emergence of vancomycin-
resistant enterococcus infections.153 Vancomycin should be
reserved for patients with known MRSA colonization, those
in facilities with recent MRSA outbreaks, and those with
known risk factors for MRSA. Risk factors for community- and
hospital-acquired MRSA include athletes in contact sports,
children at day care centers, homeless patients, IV drug users,
men who have sex with men, military personnel, prison
inmates, antibiotic use within the preceding year, crowded
living conditions, chronic wounds, those who have been
recently hospitalized or dialyzed, and those with indwelling
catheters or percutaneous medical devices.154–156 A cardiac
surgery study showed that the choice of antimicrobial used
(cefazolin vs. vancomycin) changed the infecting organism
but not the rate of SSI.157 To date, there is insufcient evidence
that changing the antibiotic prophylaxis from cephalosporins
to vancomycin in institutions with perceived high rates of
MRSA will result in fewer SSIs.158 Prophylactic dual-antibiotic
coverage with a rst-generation cephalosporin and vancomycin
should be used with caution, as there may be an increased
risk of iatrogenic acute kidney injury with this regimen159,160
and minimal decrease in the incidence of SSI.160,161 Last, the
internal xation of open fractures may demand unique
prophylactic antibiotic needs. Depending on the anatomic
location and mechanism of injury, these fractures may present
the need for additional broad-spectrum prophylactic antibiotic
coverage, such as the addition of an aminoglycoside, as they
may be contaminated with gram-negative organisms from
the gastrointestinal tract, the genitourinary tract, or
environmental contaminates such as excrement from farm
animals.162
DOSING
Because of the historic “one size ts all” xed dosing strategy,
many patients are routinely underdosed with prophylactic
antibiotics. A recent retrospective study by Kheir and col-
leagues163 of 1828 patients undergoing total joint arthroplasty,
using vancomycin as prophylactic monotherapy, demonstrated
this phenomenon, with 72% of patients receiving an incorrect
dose. Many patients are now obese, and this group in particular
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is at risk for antibiotic treatment failure. Appropriate dosing is
most likely one of the contributing factors.164 Clinicians need
to consider the relative risks of overdosing and underdosing.
Obesity causes a number of changes, including an increase
in volume of distribution and changes in hepatic metabolism
and renal excretion.165 Cefazolin should be dosed at 1 g for
patients weighing less than 80 kg, 2 g for patients between 80
and 120 kg, and 3 g for patients greater than 120 kg.6,148,166
Clindamycin and vancomycin dosing is based on the patient’s
body mass, as is pediatric dosing. Consultation with infectious
disease and pharmacy experts at the surgeon’s institution
is advised. Redosing of antibiotics can lead to suboptimal
tissue levels167 and should be done whenever the procedure
exceeds one to two times the half-life of the antibiotic157,168
or if there is signicant blood loss.169
DURATION
Historically, there had been a trend to administer prophylactic
antibiotics for longer periods than necessary. In the recent
past, for example, patients undergoing arthroplasty procedures
would be given antibiotics until either the drains were removed
or the wounds were dry. This has been shown to be
unnecessary.148,170 In nonorthopaedic procedures,171 joint
replacement surgery,172–175 and hip fracture surgery,120,176
prolonged prophylaxis has not been shown to be important
in reducing SSI rates. Although we do not know the shortest
course of antibiotics for prevention of SSI,148,149 we do know
that prolonged antibiotic usage leads to increased microbial
resistance. The current recommendation by the AAOS and
SCIP is to discontinue antimicrobial agents within 24 hours
postoperatively after elective primary joint replacement.
INTRAOPERATIVE MEANS OF
REDUCING INFECTION
Surgeons, nurses, anesthesiologists, and other members of
the operating room (OR) team are all responsible for prevent-
ing SSIs. There is not one single aspect of the OR experience
that can be singled out to make the most difference in SSI
prevention and control. Attention to small details before,
during, and after a surgical incision is critical because there
is much room for errors to occur.
THE OPERATING ROOM ENVIRONMENT
People in the OR are the primary source of particulate
matter,177,178 and the number of colony-forming units (CFUs)
in the OR directly correlates to the number of people in the
OR.6,178–181 Skin cells, “squames,” shed by people in the OR
are the primary source of particulate matter, with these cells
contaminated by normal bacterial skin ora.182–184 Although
all people shed particulate matter from their bodies, some,
known as “shedders,” produce more than others.184 The
presence of a “shedder” in the OR is associated with an
increased risk of SSI.182,185 Modifying the OR environment
through various controls and protocols has been suggested
as a method for minimizing the impact of these airborne
contaminants on SSI rates.186–188
Sir John Charnley was one of the rst to study airow in
an OR; his experience favored laminar ultraclean air systems

in joint replacement surgery, as unltered air in the OR is
known to contain greater amounts of bacteria than ltered
air.189,190 Several studies have shown a correlation between
airborne bacterial contamination and postoperative PJI.191–194
Although laminar airow (LAF) results in a statistically
signicant reduction in airborne CFUs, a statistically signicant
decrease in SSI has not been denitively shown.195–198 The
absence of a high level of evidence from randomized trials
of the ability of LAF systems to reduce SSI rates is not proof
of ineffectiveness.199 Many of the historical studies on laminar
ow changed several variables at once, making it difcult to
control for bias.177,189 The specications for modern OR design
are dictated by the American Society of Heating, Refrigerating
and Air-Conditioning Engineers (ASHRAE), under the
standard 170-2013200 (Box 23.4). Notably, the standard only
requires the ceiling-mounted air inlets to extend a minimum
of 12 inches past the surgical table. This may not cover the
instrument or back tables, and could potentially lead to
cleaner air mixing with contaminated air and depositing on
the surgical instruments.201,202
Efforts to control the amount of bacterial shedding from
hair, exposed skin, and mucous membranes of OR staff have
led to the introduction and common use of body exhaust
suits during total joint arthroplasty procedures.203,204 Although
most would agree that these suits appear to reduce bacterial
counts in the air, SSI reduction has not been observed.205,206
Notably, one recent study suggests that modern body exhaust
suits that use a positive pressure fan may in fact increase
contamination207 and that activation of the fan before
gowning may cause particulate contamination out to a
5-foot radius.208
Box 23.4 Summary of ASHRAE Standard
170-2013
1. Ceiling height between 9 and 12 feet
2. Nonaspirating diffuser ceiling air supply grid
3. Diffuser array face velocity of 25–35 feet per minute
4. 99.97%-efcient HEPA lters upstream of or part of the
ceiling grid
5. Ceiling grid size between 6 × 8 feet and 8 × 8 feet centered
over OR table
6. Up to 30% of ceiling grid can be devoted to non–airow
delivery (i.e., OR lights)
7. Ceiling grid must extend a minimum of 12 inches beyond
the OR table
8. At least two wall-mounted return grilles mounted at least
8 inches above the oor in either corner of the room
9. 20 ACH with at least 4 ACH from outdoor air
10. Room pressurized to 0.01 inches H2O (2.5 Pa) positive
relative to adjacent spaces
11. Temperature 68°–75°F (20°–24°C), relative humidity
20%–60%
ACH, Air changes per hour; HEPA, high-efciency particulate air; OR,
operating room; Pa, pascals.
From ANSI/ASHRAE/ASHE Standard 170-2017: Ventilation of Health
Care Facilities in Part 3 of the Guidelines for Design and Construction
of Hospitals (St. Louis, MO: Facility Guidelines Institute, 2018).
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CHAPTER 23 — SuRgiCAl SiTE infECTion PREvEnTion 667
OR trafc has also been shown to be a major concern
during arthroplasty procedures, especially during revision
cases.209,210 Limiting the number of people in the OR is critical
in preventing SSIs180,211 and is likely more important than
LAF.212,213 There is ongoing debate about whether door-
opening events or OR trafc itself is responsible for increasing
room contamination.209,210,214,215 Although many surgeons are
now aware of and concerned about OR trafc during a
procedure, it should be noted that greater than 50% of all
door-opening events take place during the setup of the OR,
before the patient enters the room.209,210 This is notable as
there is evidence that surgical instrument trays become
increasingly contaminated over time while open and uncov-
ered.216,217 Consideration should be given to instituting
trafc-calming measures as soon as the instrument trays are
open and covering the trays with surgical towels until they
are ready for use.216
The use of ultraviolet light (UVL) remains controversial,
as it has been shown to be effective in creating a clean-air
environment in some studies, whereas others have not
supported this argument.218–220 A study surveying almost 300
hospitals across four states showed that during total knee
replacement surgery, 30% reported regular use of LAF, 42%
reported regular use of body exhaust, and 5% reported regular
use of UVL.221 The CDC recommends further study of LAF
but recommends UVL not be used secondary to documented
potential health risks to personnel.199
The role of surgical facemasks has been surprisingly contro-
versial. Several studies have not denitively shown that CFUs
are reduced with surgical masks.178,222,223 One study, quoted
by the CDC, showed that a fresh facemask almost completely
abolished bacterial contamination of agar plates 30 cm from
the mouth.224 Interestingly, a recent study looking at more
than 800 surgical cases in an Australian tertiary care center
found no difference in infection rates when nonscrubbed
staff wore masks and when they did not.225 Another study
favored wearing a hood over a mask to reduce contamina-
tion.226 Because available data are sparse in this eld, this
chapter’s authors routinely use a facemask while entering an
arthroplasty room and have it removed after the body exhaust
suit is wrapped up. They also mandate that all OR personnel
wear a facemask throughout the extent of the procedure.
Maintaining patient normothermia during surgery plays
an important role in preventing SSI and has received a strong
recommendation by the World Health Organization (WHO).227
Traditionally, forced air warmers have been used to maintain
patient normothermia during surgical procedures and are
considered the gold standard.228 However, they have recently
come under scrutiny for being both a potential reservoir for
bacteria229–231 and for creating warm air convection currents
that may cause contamination of the surgical site during
orthopaedic procedures.232–236 Several literature reviews have
thus far failed to link these devices to an increase in SSI
rates,236–238 and the Association of Operating Room Nurses
(AORN) still considers these devices safe for use at this time.228
THE SURGICAL TEAM
Surgeons have advocated the surgical hand scrub since Lister
used carbonic acid to clean his hands.244 Considering that
glove perforation continues to be an issue,245 reducing resident
and transient ora on the skin before the incision and
668 SECTion onE — gEnERAl PRinCiPlES
achieving persistent antimicrobial activity throughout the
length of the procedure are critical. Data on the clinical
effects of a variety of surgical hand scrub protocols are lacking,
and most studies have looked at bacterial counts on the skin.
Because of the high variability of available products, there
is no standard recommended scrub. Several studies have
demonstrated that scrubbing for 5 minutes with an antimi-
crobial soap without a brush reduces bacterial counts as
effectively as a 10-minute scrub.246,247 Chlorhexidine-containing
soap has shown excellent results in bacterial load reduction
and continues to work throughout the procedure.248 Alcohol-
based hand rubs that require less time than washing hands
have shown greater effectiveness, less irritation to the hands,
and no risk of recontamination by rinsing hands with water
that may not be of the best quality.249 If one chooses to use
an alcohol-based rub, it is important to prewash the hands
and allow them to dry completely before application. Which-
ever surgical scrub or rub is used, it is critical that all staff
members are well educated about the manufacturer’s recom-
mended application technique.
Double gloving has been shown to reduce blood contact
to the hands of the operating team members by nearly 90%.250
The risk of contamination from blood can be 13 times higher
when using single compared with double gloves, and double
indicator gloves appear to be better than two regular gloves.251
Double gloving, however, has shown a similar incidence of
wound contamination compared with single gloving.252 Cloth
gloves placed over latex gloves appear to result in fewer
punctures of the inner glove.253 The puncture rate of gloves
increases in longer procedures,253 and systematic glove changes
at key phases of certain procedures such as hip arthroplasty
reduce the frequency of occult perforations and bacterial
loading of glove surface.254 Considering that double gloving
does not signicantly affect manual dexterity or tactile sensitiv-
ity compared with single gloving,255 given the available data,
it appears reasonable to recommend double gloving for the
majority of orthopaedic cases in which glove perforation is
likely to occur. Scrub staff–assisted donning of gloves should
be done whenever possible because it appears to lead to less
gown contamination.256 Notably, the use of positive pressure
body exhaust suits has been associated with air-leak at the
gown-glove interface and may serve as a potential source of
surgical wound contamination.257 Current data suggest that
surgical gowns should be occlusive, water repellent or impervi-
ous, and nonwoven.258,259 More data are needed to determine
the benets of single-use versus reusable gowns.260,261
THE SURGICAL SITE
For elective cases, surgical site preparation should start
at home before admission. Cleaning the surgical site with
an antiseptic the night before surgery has been shown to
signicantly decrease skin bacterial counts of staphylococci
and yeast.262 Repeated applications increase the efcacy.263 The
introduction of chlorhexidine wipes has made this process
efcient and easy for patient self-application.264 Consideration
should be given not only to the disinfection of the surgical
site, but also of known reservoirs of staphyloccocal carriage
such as the forehead, groin/perineum, and axillae.265,266 For
trauma cases, surgical site disinfection should start as soon
as possible before the incision. Hair removal should only
be done when there is excessive hair. Use of a safety razor
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more than 24 hours before surgery carries a 20% infection
risk,267 and shaving immediately before surgery carries a 3.1%
risk. The lowest SSI rate is associated with no hair removal
at all or with use of a depilatory method within a few hours
of surgery.268
Four surgical site preparation solutions are commonly
used: 4% chlorhexidine gluconate, povidone-iodine (Beta-
dine), 2% chlorhexidine gluconate mixed with 70% alcohol
(Chloraprep), and iodine povacrylex mixed with isopropyl
alcohol (DuraPrep).269–273 The 4% chlorhexidine gluconate
solution appears to be superior to Betadine at reducing
intrasurgical wound contamination. Betadine is as effective
as 4% chlorhexidine gluconate in decreasing initial bacterial
contamination, although the latter is less toxic and has a
more cumulative effect than the former. Chloraprep appears
to have better immediate and residual antimicrobial activity
than 4% chlorhexidine gluconate. In a study of general surgery
cases, DuraPrep was shown to have the lowest SSI rate
compared with Chloraprep and Betadine.273 Interestingly,
the chlorhexidine-based solutions may lead to more erasure
of surgical site markings used during time-out patient safety
procedures than the iodine-based products.274
The use of adhesive drapes in joint replacement surgery
is common, although it is not universally used in other
orthopaedic subspecialties. It has been proposed that these
drapes function by preventing bacterial penetration, multi-
plication, and lateral movement.275 One study found a wound
contamination reduction from 15% to 1.6% with use of an
iodophore-impregnated drape.276 A study out of Germany
looking at 123 cases with and without a drape found no
signicant difference in infection rates.277 If one chooses to
use an adhesive drape, attention must be given to prevention
of drape “lift-off.” DuraPrep appears to be superior to both
Betadine278 and Chloraprep in terms of drape adhesion.
Although many surgeons have spread the belief that “the
solution to pollution is dilution,” there is disagreement about
the most effective type of irrigation solution and the best
method of delivery. A study in hip and knee arthroplasty
patients suggested the benets of dilute Betadine lavage for
3 minutes before wound closure.279 Similar ndings have
been shown using the same method in spine surgery cases.280
WHO guidelines now give a weak recommendation for the
routine use of dilute Betadine lavage for the prevention of
SSI, although they acknowledge that the quality of evidence
is low.227 Although antibiotic irrigation does not appear
to be effective in reducing SSI rates,281 an in vitro animal
wound model showed that surfactant irrigation was superior
to saline or antibiotic solution in removing bacteria from
metallic surfaces, bone, and bovine muscle. Interestingly,
not much work has been done on the ideal amount of
irrigation uid. One study on removal of cement debris in
knee arthroplasty procedures suggested that 4 L of irrigation
solution is needed.282 Pulsatile lavage appears to be superior to
bulb-syringe irrigation283; however, attention should be given
to maintain a relatively low pressure because high-pressure
lavage can lead to deep tissue bacterial penetration and
retention compared with low-pressure pulsatile lavage.284
A recent single-blind, randomized, prospective controlled
trial examined the effect of lavage type (high pressure, low
pressure, and very low pressure) and type of solution (normal
saline vs. castile soap) on reoperation rates after irrigation
of open fractures and found no difference in the rate of

reoperation between the irrigation pressures, but found that
saline lavage appeared to be superior to that of castile soap.285
Suction tips286,287 and irrigation splash basins288,289 are also
sources of potential bacterial contamination. Suction tips
become contaminated during orthopaedic procedures, with
one study showing a 54% contamination rate, 77% of which
were with staphyloccal species.290 Consideration should be
given to changing suction tips during lengthy procedures,
although data specically supporting when during a procedure
this should occur are lacking.
CONCLUSION
Surgical site infections continue to be serious, potentially
life-threatening complications of surgery. The social burden
of these infections is immense.291,292 SSIs will always be present
and cannot be completely eliminated. New technologies that
tether prophylactic antimicrobials to implants have shown
promising results,293,294 as have simpler methods such as
antibiotic-loaded bone cement in arthroplasty cases295 and
direct placement of antibiotics into the wound itself.296,297
The emerging paradigm of infection prevention and control
discussed in this chapter should serve as a foundation for
minimizing this devastating complication.
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