Orthopaedic Surgical Wound Infection Management Pathway

These materials are intended for general clinical education and guidance. They are not a substitute for a clinician’s knowledge, skill or judgment in treating patients.

Table of contents

1. Definitions and initial assessment
2. Imaging
3. Microbiology
4. Wound care
5. Antibiotic therapy

1. Definitions and initial assessment

Surgical wound infection

Involves only skin and/or subcutaneous tissue of the incision and the patient has one or more of the following:

• Purulent drainage
• Localized pain/tenderness, localized swelling, erythema or warmth
• Onset is typically within 30 days of index surgery; if onset is greater than 30 days, consider ruling out deeper (joint) infection

NOT considered superficial SSI: stitch abscess alone confined to the points of suture penetration.

If suspicion of joint infection

• Serum CRP and ESR
• If febrile: 2 sets of blood cultures
• Arthrocentesis (2 separate samples):
  • Cell count and differential, crystals and synovial CRP ⟶ send 2 mL or more in a sterile container
  • Gram stain, culture and sensitivity ⟶ send 3.5 mL or more in a sterile container

Note: If no improvement after one week, consider non-infectious etiologies or deeper (joint) infection. If symptom onset is beyond 30 days after index surgery, wound infection is unlikely to represent a superficial SSI. Additional investigations may be warranted.

2. Imaging

Ultrasound, as per physician preference, to assess depth of soft tissue changes and rule out collection (for hips only).

Note: Plain film is helpful for assessing implant positioning, but not for detecting infection.

3. Microbiology

Usually NOT indicated. If an abscess is drained, send all available material to Microbiology in a sterile container.

Avoid superficial wound swabs.

4. Wound care

Consider use of a dressing with antiseptic or antimicrobial properties (e.g., AMD PHMB, Aquacel Ag+, Inadine).

Surgical wounds post-arthroplasty should never be packed unless specifically ordered by the primary surgeon.

5. Antibiotic therapy

1st line

_{Add MRSA coverage if known MRSA colonized.}