Keys To Managing Postoperative Wound Infections

Ryan Fitzgerald, DPM, FACFAS

What The Literature Reveals About Preventative Measures

It is said that an “ounce of prevention is worth a pound of cure.” This is especially the case with the development of surgical site infections. Researchers have shown that preventative measures significantly reduce the risk for the development of surgical site infections in numerous patient populations.22-28 Preventative measures, such as prophylactic antibiotics and the use of skin preparations prior to incision, are geared to address extrinsic risk factors, most commonly those risk factors associated with surgical procedure. One can also attempt to address intrinsic patient factors such as tobacco usage via smoking cessation modalities. In those patients with concomitant medical issues, a delay of elective surgery until the patient has greater medical management can further reduce the risk of surgical site infections.

   While it is common to use antibiotic prophylaxis in foot and ankle surgery to reduce the incidence of surgical site infections, the use of antibiotics is controversial.22 Historically, surgeons have utilized antibiotic prophylaxis in four different scenarios: 1) when incorporating implantable devices (these implanted devices often lower the bacterial burden necessary to cause wound infection); 2) in cases of trauma or limb salvage; 3) in cases involving prolonged operating time (greater than two hours); and 4) in cases involving immunocompromised patients.22,23

   Most would agree that the use of perioperative antibiotic therapy is indicated for dirty or contaminated wounds, and for those procedures known to carry a greater risk of the potential for the development of surgical site infections, including those procedures in which surgeons are utilizing hardware or implants.23

   The Infectious Diseases Society of America (IDSA) maintains evidence-based guidelines for antimicrobial prophylaxsis in surgery. There are regular updates to these guidelines, which can provide the clinician with vital information about the drug, dose and timing for effective perioperative reduction of surgical site infections.24

   However, the use of prophylactic antibiotics remains a controversial issue in clean, elective foot and ankle surgery. Indeed, one must realize that the use of preoperative antibiotics may not always be necessary for ensuring successful outcomes. Surgeons should avoid the careless use of antibiotics. Current recommendations for regarding prophylactic antibiotic usage indicate that following appropriate antibiotic selection, the patient should receive the relevant antibiotic within 60 minutes of surgery and antibiosis should not be continued more than 24 hours following surgery.24

   Surgeons may also deliver antibiotics locally with the use of antibiotic impregnated beads. Generally, the beads are infused with an aminoglycoside, such as gentamicin or vancomycin, because these agents are active against the most common pathogens and offer heat-stable properties.25 These beads deliver high levels of the antibiotic locally with little systemic uptake and systemic toxicity is not a concern. Many authors have advocated the benefits of antibiotic beads in foot and ankle surgery.26,29

   In addition to the use of preoperative antibiotics and antibiotic beads intraoperatively, perioperative patient care has further evolved to reduce the risk of surgical site infections. Among these functions, preoperative preparation of the surgical area reportedly lowers the rate of postoperative infection.27-28 To prepare the skin, shaving is no longer recommended. When necessary, one can remove hair with clippers. Shaving leaves the skin with the potential for small lacerations, which can increase the risk of colonization and subsequent infection postoperatively.27

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