Professional Documents
Culture Documents
Chlorhexidine +++ ++ ++ ++ ++
Triclosan ++ ++ ++ + −
• Disinfectants that penetrate the oily environment are
absorbed by the body and have potentially toxic side
effects.
• Hexachlorophene has better penetration, but also has
neurotoxic side effects.
• Hand washing is the most important procedure for
prevention of nosocomial infections.
• Studies suggest that hand scrubbing for 2 minutes is as
effective as traditional hand scrubbing for 5 minutes.
• The optimal duration of hand scrubbing has yet to be
determined.
• Hand rubbing with an aqueous alcohol solution that is
preceded by a 1-minute nonantiseptic hand washing for the
first case of the day was found to be just as effective in
prevention of surgical site infections as traditional hand
• Hair removal at the operative site is not recommended
unless done in the operating room.
• Shaving the operative site the night before surgery can
cause local trauma that produces a favorable
environment for bacterial reproduction.
• Glove perforation has been reported to occur in 48% of
operations.
• Most frequently, the perforation occurs on the index
finger or thumb of the nondominant hand.
• At a minimum, surgical gloves should be changed every
2 hours.
• Operating Room Environment
– Airborne bacteria are another source of wound
contamination in the operating room.
– These bacteria usually are gram-positive and originate
almost exclusively from humans in the operating room
– Conventional operating room air may contain 10 to 15
bacteria per cubic foot.
– Airborne bacterial concentrations in the operating room
may be reduced by at least 80% with laminar-airflow
systems and even more with personnel-isolator systems.
• Wound contamination rates have been reported to be reduced by
80% with the use of these systems.
• Prophylactic Antibiotic Therapy
– Many studies have shown the effectiveness of prophylactic
antibiotics in reducing infection rates after orthopaedic
procedures.
– During the first 24 hours, infection depends on the number
of bacteria present.
– During the first 2 hours, the host defense mechanism
works to decrease the overall number of bacteria.
– During the next 4 hours, the number of bacteria remains
fairly constant, with the bacteria that are multiplying and
the bacteria that are being killed by the host defenses
being about equal.
– These first 6 hours are called the “golden period,” after
which the bacteria multiply exponentially.
– Antibiotics decrease bacterial growth geometrically and
delay the reproduction of the bacteria.
– The administration of prophylactic antibiotics expands the
• A prophylactic antibiotic should be safe, bactericidal, and
effective against the most common organisms causing
infections in orthopaedic surgery.
• Because the patient's skin remains the major source of
orthopaedic infection, prophylactic antibiotics should be
directed against the organism most commonly found on
the skin, which is S. aureus, although the frequency of
Staphylococcus epidermidis is increasing.
• This increase in S. epidermidis is important because this
organism has antibiotic resistance and often gives
erroneous sensitivity data.
• Escherichia coli and Proteus organisms also should be
covered by antibiotic prophylaxis.
• In the United States, first-generation cephalosporins
have been favored for many reasons.
• They are relatively nontoxic, inexpensive, and
effective against most potential pathogens in
orthopaedic surgery. Cephalosporins are more
effective against S. epidermidis than are
semisynthetic penicillins.
• Clindamycin can be given if a patient has a history of
anaphylaxis to penicillin.
• Routine use of vancomycin for prophylaxis should be
• A prophylactic antibiotic should be safe, bactericidal, and
effective against the most common organisms causing
infections in orthopaedic surgery.
• Because the patient's skin remains the major source of
orthopaedic infection, prophylactic antibiotics should be
directed against the organism most commonly found on the
skin, which is S. aureus, although the frequency of
Staphylococcus epidermidis is increasing.
• This increase in S. epidermidis is important because this
organism has antibiotic resistance and often gives
erroneous sensitivity data.
• Escherichia coli and Proteus organisms also should be
covered by antibiotic prophylaxis.
• In the United States, first-generation cephalosporins
have been favored for many reasons.
• They are relatively nontoxic, inexpensive, and
effective against most potential pathogens in
orthopaedic surgery.
• Cephalosporins are more effective against S.
epidermidis than are semisynthetic penicillins.
• Clindamycin can be given if a patient has a history
of anaphylaxis to penicillin.
• Routine use of vancomycin for prophylaxis should
be avoided
• Ideally, antibiotic therapy should begin immediately
before surgery (≤2 hours before incision and ideally 30
minutes before skin incision).
• A maximal dose of antibiotic should be given and can
be repeated every 4 hours intraoperatively or whenever
the blood loss exceeds 1000 to 1500 mL.
• Little is gained by extending antibiotic coverage over
72 hours, and the possibility of side effects, such as
thrombophlebitis, allergic reactions, superinfections, or
drug fever, is increased.
• Barie suggested that prophylactic antibiotics should
not be extended past 24 hours even if drains and
catheters are still in place.
• Namias et al. found that antibiotic coverage for
longer than 4 days led to increased bacteremia and
intravenous line infections in patients in intensive
care units.
• Evidence now shows that 24 hours of antibiotic
administration is just as beneficial as 48 to 72 hours.
• Antibiotic irrigation has not found a definite role in
orthopaedic surgery but in vitro test showed benefit.
• When a topical antibiotic is used, it should have
– a wide spectrum of antibacterial activity,
– the ability to remain in contact with normal tissues without
causing significant local irritation,
– low systemic absorption and toxicity,
– low allergenicity,
– minimal potential to induce bacterial resistance,
– availability in a topical preparation that can be easily
suspended in a physiological solution.
• Triple-antibiotic solution (neomycin, polymyxin, and
bacitracin) is most commonly used for wound
irrigation in orthopedics.
• The importance of irrigation and débridement in the
treatment of open fractures has been well
documented.
• The principles of elimination of devitalized tissue and
dead space, evacuation of hematomas, and soft-
tissue coverage also can be applied to “clean”
orthopaedic cases.
• DIAGNOSIS
– The diagnosis of infection may be obvious or obscure.
– Signs and symptoms vary with the rate and extent of bone and
joint involvement.
– The classic triad is fever, swelling, and tenderness or pain.
– Pain probably is the most common symptom.
– Fever is not always a consistent finding.
– Infection also may be as indolent as a progressive backache or
a decrease in or loss of function of an extremity.
– No single test is able to serve as a definitive indicator of the
presence of musculoskeletal infection
• Laboratory Studies
– A complete blood count, including differential and
erythrocyte sedimentation rate (ESR) and C-reactive
protein, should be obtained .
– The white blood cell count is an unreliable indicator of
infection and often is normal even when infection is
present.
– The differential shows increases in neutrophils in acute
infections.
– The ESR becomes elevated when infection is present, but
this does not occur exclusively in the presence of
infection.
• The ESR also is unreliable in neonates, patients with sickle
cell disease, patients taking steroids, and patients whose
symptoms have been present for less than 48 hours.
• Peak elevation of the ESR occurs at 3 to 5 days after infection
and returns to normal approximately 3 weeks after treatment
is begun.
• C-reactive protein, synthesized by the liver in response to
infection, is a better way to follow the response of infection
to treatment.
• C-reactive protein increases within 6 hours of infection,
reaches a peak elevation 2 days after infection, and returns to
normal within 1 week after adequate treatment has begun.
• Material obtained from aspiration of joint fluid can be sent to
the laboratory for a cell count and differential to distinguish
acute septic arthritis from other causes of arthritis.
• In septic arthritis, the cell count usually is greater than 80,000,
with more than 75% of the cells being neutrophils.
• A Gram stain also should be obtained: in about a third of
bone and joint aspirates positive.
• Intraoperative frozen section also should be obtained in cases
in which infection is suspected.
– A white blood cell count greater than 10 per high-power field is
considered indicative of infection, whereas a count less than 5
per high-power field all but excludes infection
Synovial Fluid Analysis
>2 y S. aureus
Medical Conditions
Streptococci
Adolescents and Neisseria Ceftriaxone or cefotaxime 1-2 g 1
adults with possible gonorrhoeae
STD
S. aureus 3-6 g 3
Enterobacteriaceae 5 mg/kg 3
Streptococci 3-6 g 3
Gram-negative 800 mg 2
bacilli including
Pseudomonas 5 mg/kg 3
species
Antibacterial Therapy of Bacterial Arthritis after Culture and Susceptibility Results