Review Article

Local Modalities for Preventing

Surgical Site Infections: An
Evidence-based Review

Abstract
Julia A. Katarincic, MD Surgical site infections remain a dreaded complication of orthopaedic
Amanda Fantry, MD surgery, affecting both patient economics and quality of life. It is
important to note that infections are multifactorial, involving both surgical
J. Mason DePasse, MD
and patient factors. To decrease the occurrence of infections, surgeons
Ross Feller, MD frequently use local modalities, such as methicillin-resistant
Staphylococcus aureus screening; preoperative bathing; intraoperative
povidone-iodine lavage; and application of vancomycin powder,
silver-impregnated dressings, and incisional negative-pressure wound
therapy. These modalities can be applied individually or in concert
to reduce the incidence of surgical site infections. Despite their
frequent use, however, these interventions have limited support in the
literature.

M ore than 35,000 surgical site

From the Department of Orthopaedic
Surgery, Warren Alpert Medical
School at Brown University, Rhode
Island Hospital, Providence, RI.
Dr. DePasse or an immediate family
member has received nonincome
support (such as equipment or
services), commercially derived
honoraria, or other non2research-
related funding (such as paid travel)
from Stryker. None of the following
authors or any immediate family
member has received anything of
value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Katarincic, Dr. Fantry, and
Dr. Feller.
J Am Acad Orthop Surg 2018;26:
14-25
DOI: 10.5435/JAAOS-D-16-00033
Copyright 2017 by the American
Academy of Orthopaedic Surgeons.
infections (SSIs) after ortho-
paedic surgery are estimated to occur
annually in the United States.1 This
includes up to 20,000 infections
contracted by arthroplasty patients
each year.1,2 SSIs not only increase a
patient’s hospital length of stay by 7
to 14 days, but they also increase the
likelihood of being in the intensive
care unit by 60%, increase median
total direct costs by .300%, and
double the risks of rehospitalization
and death.2,3
Both host- and procedure-specific
modifiable and nonmodifiable fac-
tors for SSIs are well documented.
These factors include obesity, smok-
ing, diabetes mellitus, rheumatoid
arthritis, preoperative anemia, esti-
mated blood loss of .1 L, and nasal
carriage of Staphylococcus aureus
(ie, for S aureus infections).1
Harrop et al4 cited proper surgical
site skin preparation, handwashing,
hair shaving, operating room (OR)
behavior (to provide strict adherence
to sterile technique), surgery dura-
tion, and modification of patient-
related risk factors as strategies to
decrease the incidence of infection.
In addition to expanded awareness
and modification of general OR
activity and behaviors, preoperative
and intraoperative local modalities
to prevent SSIs include preoperative
methicillin-resistant S aureus (MRSA)
screening, chlorhexidine bathing, irri-
gation with povidone-iodine or other
additives during wound lavage, local
application of vancomycin powder,
and the use of incisional negative-
pressure wound therapy (INPWT)
and occlusive dressings.
Preoperative Modalities
MRSA Screening
In orthopaedic surgery, S aureus is
the most common cause of SSIs.5,6
In fact, nasal carriage of S aureus
was previously identified as the
only independent risk factor for

14 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

S aureus infection after orthopaedic
surgery.7
Methicillin-sensitive S aureus and
MRSA nasal carriage rates vary
worldwide but were estimated to be
approximately 28.6% and 1.5%,
respectively, in the United States from
2003 to 2004.8 Patients who are
carriers of S aureus have an increased
likelihood of developing an S aureus
infection; according to one study, the
molecular isolates from a patient’s
wound infection matched the nares’
strain 86% of the time.9
S aureus can be detected with a
traditional culture of the nares or via
polymerase chain reaction (PCR)
testing. In hospitalized patients, the
chief advantage of PCR testing is
prompt detection of the bacteria;
results are typically available within
24 hours. In contrast, culture results
can take 2 to 4 days to process but
are substantially cheaper, although
costs vary among institutions.5,10
Multiple studies have examined the
use of screening and decolonization
programs to reduce S aureus coloni-
zation rates.6 The most common
method for decolonization of the
bacteria is nasal mupirocin with
or without chlorhexidine bathing.
Mupirocin is approved by the US
FDA and is available as a 2% nasal
ointment applied twice daily, with a
5-day course of treatment before
surgery typically used.11-15 How-
ever, mupirocin is not recommended
for empiric treatment of all patients
because of the risk of S aureus strains’
developing drug resistance.10
A recent systematic review of 19
studies involving orthopaedic sur-
gery patients demonstrated a reduc-
tion in SSIs after an S aureus
screening and decolonization pro-
tocol was adopted.6 Reductions of
29% to 149% were observed in all
SSIs, methicillin-sensitive S aureus
infections, and MRSA infections.
However, five of these studies were
underpowered, and the reductions
did not reach statistical significance.
January 1, 2018, Vol 26, No 1
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
The literature supports preoperative
treatment of patients colonized with
MRSA, with multiple reviews advising
institution of a screening and decolo-
nization protocol as a grade B recom-
mendation to reduce SSIs caused by
MRSA.5,6,10 Screening elective sur-
gery patients with traditional culture
methods is cheaper than using PCR
testing but requires a longer turn-
around time. Decolonization proto-
cols should combine nasal mupirocin
treatment and chlorhexidine bathing,
but this should not be used as empiric
treatment for patients without MRSA
carriage.
Chlorhexidine Bathing
Chlorhexidine, which is currently
available as a 4% solution and a 2%
cloth formulation for preoperative use,
is bacteriostatic and bactericidal, de-
pending on the concentration. This
agent was more effective than
povidone-iodine was at eliminating
gram-positive bacteria4 and decreased
the number of bacteria on the skin,
particularly transient flora, with a less
notable decrease in resident flora (ie,
bacteria within the hair follicles and
sebaceous glands).16 The use of chlor-
hexidine has also decreased hospital-
acquired infections in the intensive care
unit and has been effective against
both MRSA and vancomycin-resistant
Enterococcus. The effect of chlorhexi-
dine is cumulative and increases with
multiple administrations and duration
of use.16
Research on the efficacy of chlor-
hexidine in preventing SSIs has
mixed results. In their fifth evalua-
tion of the literature, Webster and
Osborne16 reported no new updates
since the previous review, which
included six studies published
between 1983 and 1992 and one
study from 2009. The review also
had multiple limitations, including
major heterogeneity in case con-
tamination, variation in the number
of times patients were instructed to
Julia A. Katarincic, MD, et al
bathe, substantial variability in
bathing instructions, and inade-
quacy of postoperative surveillance
for SSIs. Only one study used pre-
operative prophylactic antibiotics.
In addition, most studies did not use
chlorhexidine-alcohol for surgical
preparation, which is currently the
most commonly used solution.
Despite these limitations, the review
included .10,000 patients and
compared the use of chlorhexidine
with the use of placebo, bar soap, or
no preoperative bathing. The
authors concluded that, although
no clear evidence showed that
chlorhexidine was more effective
than placebo or bar soap at reduc-
ing SSI rates, chlorhexidine was
more effective than not bathing at
all. The studies also reported fewer
skin surface bacteria and less yeast
growth with the use of chlorhex-
idine but no change in infection
rates.
In a study of .3,700 patients who
underwent total joint arthroplasty
(TJA), 1,891 of whom used 2%
chlorhexidine wipes locally at the
surgical site 1 hour before surgery,
no difference in infection rates as a
result of this protocol was found at
1-year follow-up.17 Moreover, a
recent meta-analysis of 16 trials
(nearly 18,000 patients) compared
the efficacy of chlorhexidine bathing
versus placebo or no preoperative
shower in reducing SSIs.3 The
authors determined that the infection
rate was 6.8% in the chlorhexidine
group and 7.2% among all com-
parator groups (P = 0.19). Limita-
tions of the study included lack of
standardization in the number of
preoperative baths (zero to 3) and
the time the solution was left in place,
as well as dated studies (ie, 12 of the
16 studies were published before
1993); nevertheless, three of the four
remaining studies demonstrated that
the use of chlorhexidine bathing
decreased wound infections. In con-
trast, Edmiston et al18 found that
15
Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review
chlorhexidine considerably decreased
the infection rate in a review of studies
on the subject that were published
from 2009 through 20153,16,17,19-24
(Table 1).
Determining the level of compliance
among patients instructed to use a
preoperative protocol is difficult,
which may contribute to the lack of
consensus regarding its benefits. In a
2015 study, 4,751 patients were given
instructions on how to use chlorhex-
idine wipes before TJA.25 The patients
were required to affix a sticker from
the chlorhexidine package to a sheet
that they were to present on the day of
surgery. Despite the focus on the
protocol, 78% of patients were
noncompliant.
Supple et al26 described the use of a
colorimetric assay in male patients
(mean age, 65 years) to determine the
concentration of chlorhexidine on the
skin after preoperative bathing with a
4% chlorhexidine solution or cloth
wipes. The authors found that only
46% of patients who used the chlor-
hexidine solution were compliant,
whereas 70% of those who used cloth
wipes were compliant. Patients using
cloth wipes also had a significantly
higher concentration of chlorhexidine
on their skin (P , 0.001). After a
nursing intervention to educate
patients on the appropriate use of
wipes, 88% were compliant with
preoperative bathing.
In prospective randomized trial,
Edmiston et al27 randomly assigned
120 healthy patients to either a two-
shower group or three-shower group
and rinsing subgroups in which
patients had no pause before rinsing,
a 1-minute pause, or a 2-minute
pause. There was no difference in
the mean chlorhexidine concentra-
tion on the skin surface in patients
taking two or three showers; how-
ever, a statistically significant differ-
ence in chlorhexidine concentration
was found between the no-pause rinse
subgroup and both the 1- and
2-minute pause subgroups (P ,
16
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
0.001). Among the patients in the
two- and three-shower groups, no
difference in skin surface concentra-
tion of chlorhexidine was found
between the 1- and 2-minute pause
subgroups.
In another study, Edmiston et al28
randomized 80 patients to four
showering groups. Patients in groups
A1 and A2 showered twice, with
patients in group A1 receiving an
electronic alert message to enhance
compliance with the protocol,
whereas patients in groups B1 and B2
showered three times, with patients
in group B2 receiving an alert mes-
sage. Patients receiving a voicemail,
text, or email reminding them to
complete the preoperative protocol
had a significantly higher concen-
tration of chlorhexidine on their skin
than those who did not receive an
alert (P , 0.007). As in the previous
study by Edmiston et al,27 there was
no difference in the mean chlorhex-
idine concentration on the skin sur-
face in patients taking two or three
showers.28
Intraoperative Measures
Adhesive Draping
Adhesive draping may prevent intra-
operative contamination and recolo-
nization of the skin, can protect
wounds from microorganisms pres-
ent on the skin, and can provide
additional antimicrobial benefits in
drapes impregnated with iodine. The
downsides to adhesive draping
include a possible greenhouse-like
effect that results in increased secre-
tion of bacteria by hair follicles and
sebaceous glands. This added flora
may then reach the wound, particu-
larly when the drape is peeled back
during surgery.
Webster and Alghamdi29 analyzed
seven randomized controlled trials
conducted from 1971 to 2002; five
studies compared adhesive draping
with nonadhesive draping, and two
Journal of the American Academy of Orthopaedic Surgeons
studies compared iodine-impregnated
adhesive drapes with nonadhesive
drapes. Only one of the seven studies
involved orthopaedic surgery. Sur-
prisingly, the use of adhesive drapes
increased the risk of SSIs relative to
no draping (risk ratio, 1.23; confi-
dence interval, 1.02 to 1.48; P = 0.03),
and the use of iodine-impregnated
drapes made no difference in infec-
tion rates.
In a more recent study that was not
included in the review by Webster
and Alghamdi,29 10 healthy volun-
teers were taken to the OR, where
the left chest was covered with Te-
gaderm (3M Medical) after being
prepared in standard fashion with
chlorhexidine prewash and Chlora-
Prep (Becton Dickinson).30 Skin
swabs were collected 3 days before
the trial, before and after ChloraPrep
application, and eight times during 6
hours in the OR. Recolonization
occurred as quickly as 30 minutes
but was much more extensive in the
adhesive drape group than in the
group without the drape (31% ver-
sus 7.5%; P , 0.0001). All cultures
were positive for coagulase-negative
staphylococci (CoNS). The same
authors then performed a separate
randomized controlled trial to
determine the need for plastic adhe-
sive drapes in cardiac surgery.31
Patients bathed with chlorhexidine
at home, and a 0.5% solution of
chlorhexidine in ethanol was used
for surgical preparation. Skin sam-
ples were collected preoperatively
and every hour during surgery for
up to 6 hours. At 2 hours, 44.6% of
cultures in the adhesive drape group
had grown CoNS, whereas only
23.8% in the bare skin group had
grown CoNS. In addition, the per-
centage of CoNS increased even in
the subcutaneous tissues by the end
of surgery. Progressive recolonization
of Propionibacterium acnes also
occurred between 120 and
180 minutes, with a significant dif-
ference in the number of patients
 Julia A. Katarincic, MD, et al

Table 1
The Effect of Chlorhexidine Prewash on Wound Infection Rate
No. of Results and
No. of Prewash Prewashes Study Level of
Study/Type Patients Case Type Solutions (Timing) Limitations Evidence

Webster and 10,157 All surgical Chlorhexidine, Varied: 1, 2, or 3 Results: No clear I

Osborn16 patients, bar soap, evidence that
Cochrane including clean placebo, no chlorhexidine
review with and wash was better than
seven RCTs contaminated placebo or bar
cases soap
Limitations: Poor
study designs;
poor follow-up;
prophylactic
antibiotics used
in only one
study;
inadequate
postoperative
surveillance for
infection
Farber et al17 3,715 Total joint 2% chlorhexidine One (1 hr Results: No III
retrospective arthroplasty wipes preoperatively) reduction in
medical record infection at 1 yr
review before between two
and after groups
intervention Limitations:
Retrospective
design; only one
prewash used
Chlebicki et al3 17,932 All surgical Chlorhexidine, bar Varied: 1, 2, or 3 Results: No III
meta-analysis patients, soap, placebo, significant
including clean no bath/ reduction in
and noncompliant infections with
contaminated patients chlorhexidine in
cases comparison to
other groups;
three of four
studies
published after
1992 did
demonstrate an
infection rate
reduction
Limitations:
Poor study
designs; unclear
definitions of
SSI; outdated
studies
Eiselt19 1,463 Total joint 2% chlorhexidine Two (night before Results: 50.2% III
sequential arthroplasty wipes and morning of reduction in SSIs
cohort surgery) after
implementation
of CHG prewash
Limitation:
Single-institution
study
(continued )
CHG = chlorhexidine gluconate, SSI = surgical site infection

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Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review

Table 1 (continued )
The Effect of Chlorhexidine Prewash on Wound Infection Rate
No. of Results and
No. of Prewash Prewashes Study Level of
Study/Type Patients Case Type Solutions (Timing) Limitations Evidence

Dizer et al20 82 Abdominal surgery 4% chlorhexidine Two (during Results: III

retrospective in hospital solution hospitalization Significantly
cohort inpatients and the night decreased
before surgery) infection rate in
preoperative
CHG group (P ,
0.005) Limitation:
Small study size
Johnson et al21 954 Total joint 2% chlorhexidine Two (night before Results: 1.6% II
prospective arthroplasty wipes and morning of infection rate
cohort surgery) among
noncompliant
patients; 0%
among compliant
patients
Limitation: Poor
compliance (ie,
157 of 954
patients)
Graling and 569 General, vascular, 2% chlorhexidine One (3 hr Results: III
Vasaly22 orthopaedic wipes preoperatively) Significantly
prospective surgery decreased
cohort infection rate in
preoperative
CHG group (P ,
0.01) Limitation:
Single-institution
study
Johnson et al23 2,213 Total joint 2% chlorhexidine Two (night before Results: III
retrospective arthroplasty wipes and morning of Considerably
cohort surgery) decreased
infection rate in
preoperative
CHG group
Limitation:
Single-institution
study
Kapadia et al24 2,458 Total joint 2% chlorhexidine Two (night before Results: III
prospective arthroplasty wipes and morning of Considerably
cohort surgery) decreased
infection rate in
preoperative
CHG group (P =
0.04) Limitation:
Substantially
different cohort
sizes

CHG = chlorhexidine gluconate, SSI = surgical site infection

with an infection in the adhesive findings, the authors’ institution use of plastic surgical adhesive tape
drape group compared with patients stopped using adhesive drapes.31 and paper drapes for surgical site
in the no drape group at 120 minutes Several authors have noted that draping to prevent infection after
(P = 0.03). As a result of these strong evidence exists to support the TJA. Another study found that,

18 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

compared with traditional plastic
adhesive tape, iodine-impregnated
drapes slow recolonization.32-36 Fur-
ther investigation of the cita-
tions revealed that the most recent
article suggesting elimination of
reusable drapes was published in
2002, and the only article discussing
iodine-impregnated drapes is a one-
page paper involving 15 patients that
was published in 1987. In addition, a
2015 review article of perioperative
skin preparation and draping in TJA
concluded that adhesive draping was
unnecessary.37 Thus, despite its
popularity, limited studies support
the use of adhesive draping in
orthopaedic surgery.
Povidone-iodine Irrigation
Povidone-iodine is safe, inexpensive,
and readily available. It is bacteri-
cidal at 0.5% to 4% concentrations
and works by downregulating an
operon necessary for biofilm forma-
tion. Although evidence supporting
the use of povidone-iodine irrigation
is limited in the orthopaedic litera-
ture, other surgical specialties have
reported ample data regarding its use,
including evidence that povidone-
iodine was effective against even the
most resistant forms of MRSA at
3 minutes.38,39 Although it was
found to be cytotoxic to chicken
tibia osteoblasts at concentrations
.5%, there are few disadvantages to
the use of povidone-iodine
irrigation.40
A 2007 review of 15 multidisci-
plinary studies found a considerable
decrease in infection rates associated
with the use of povidone-iodine irri-
gation in 10 of the studies.41 How-
ever, there was no standardization in
the povidone-iodine concentration,
amount of irrigation, wound class,
or antibiotics used. Only two of the
studies were from the orthopaedic
literature (spine surgery), and in both
studies, patients received cefazolin
and gentamicin 48 hours post-
January 1, 2018, Vol 26, No 1
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
operatively followed by a 3-day
course of cephalexin.40,42 Wounds
were irrigated with 0.35%
povidone-iodine before closure and
soaked for 3 minutes before rinsing
and irrigation with normal saline.
Both studies reported a decrease in
SSIs with povidone-iodine irrigation.
In a more recent study from the TJA
literature, wounds were soaked for
3 minutes in 0.35% povidone-iodine
solution, after which pulse lavage
with normal saline was done before
closure.43 Compared with the infec-
tion rate of TJA procedures done
without this lavage protocol, the
infection rate of TJA performed with
povidone-iodine irrigation was sig-
nificantly reduced at 90 days post-
operatively (0.97% versus 0.15%;
P = 0.04).
Although povidone-iodine may
limit postoperative SSIs, only three
relevant studies are available in the
orthopaedic surgery litera-
ture.40,42,43 When povidone-iodine
irrigation is considered for pro-
tection against infection, it must be
left in the wound for 3 minutes to kill
all strains of MRSA. To generate a
0.35% povidone-iodine solution,
approximately 105 mL of 10%
povidone-iodine should be mixed
into a 3-L bag of normal saline (or 35
mL/1,000 mL). Povidone-iodine
must be delivered in a sterile form,
because the unsterile form in the
plastic bottle may harbor pathogens
and contaminate the wound.
Vancomycin Powder
Only recently has the use of vanco-
mycin powder increased in subspe-
cialties other than cardiothoracic
surgery, including orthopaedic sur-
gery. Vancomycin is bactericidal and
reaches a high concentration in a
local environment with poor systemic
absorption. When used locally, van-
comycin is much less cytotoxic than
gentamicin or ciprofloxacin; osteo-
cyte viability remains unchanged
Julia A. Katarincic, MD, et al
until vancomycin concentrations
reach .5,000 mg/mL.44 In a study
examining mean serum and drain
levels of vancomycin, the peak level
recorded in the drain was 403 mg/mL
on postoperative day zero, far below
the cytotoxic concentration.45
Concerns have been raised about
the potential risks of local use of
vancomycin, including selection for
gram-negative and multidrug-
resistant bacteria, increased local tis-
sue irritation, hypersensitivity or
anaphylaxis, impaired renal func-
tion, and increased seroma forma-
tion. However, these adverse effects
are mostly hypothetical and have
not been borne out in the literature.
Furthermore, there is no standard-
ized dose or recommended tissue
layer of application, and local use of
vancomycin is not approved by the
US FDA.
Recent evidence supports the local
application of vancomycin powder in
spine surgery45-54 (Table 2). O’Neill
et al55 and Sweet et al56 investigated
the use of vancomycin powder in
posterior spinal fusion for trauma
and elective thoracolumbar fusions.
Both studies demonstrated signifi-
cantly fewer infections in the group
receiving local vancomycin powder
and standard system prophylactic
antibiotics than in the group receiv-
ing standard systemic prophylactic
antibiotics alone (13% versus 0%;
P = 0.0255 and 2.6% versus 0.2%;
P , 0.000156). Sweet et al56 checked
the levels of vancomycin present in
serum and wound drains. In that
study, only 6% of patients had a
detectable level of vancomycin in
their blood after postoperative day 1,
whereas the level of vancomycin in
the drain remained elevated for the
first 3 postoperative days.
In a 2015 systematic literature
review investigating local vancomy-
cin use in spine surgery, 17 of 19
studies reported a lower infection rate
among patients treated with vanco-
mycin powder compared with those
19
Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review

Table 2
The Effect of Local Application of Vancomycin on Infection Rates in Patients Undergoing Spine Surgery
Results and
No. of Vancomycin Study Level of
Study/Type Patients Case Type Powder Dose Location Limitations Evidence

Tubaki et al46 907 All spine cases 1g Results: No

Deep and II
prospective significant
superficial
randomized withindifference in
controlled trial wound infection rates
Limitations: Did not
include smoking
rates or BMI.
Antibiotics given
until drain
removed.
Heller et al47 683 Posterior spinal 0.522 g Superficial Results: Significant III
retrospective fusion (varied by size within decrease in
cohort of wound) wound infection rate (P =
0.029) Limitations:
Retrospective study
Kim et al48 74 Anterior and posterior 1g Deep and Results: Significant III
retrospective spinal fusion, all superficial decrease in
cohort levels within infection rate (P ,
wound 0.033) Limitations:
Retrospective
study; patients
given antibiotics
until drain removed
Godil et al49 110 Instrumented 1g Deep and Results: Significant III
retrospective posterior fusion for superficial decrease in
cohort trauma within wound infection rate (P =
0.02) Limitations:
Retrospective
study; surgeons in
vancomycin group
and control group
were different
Ghobrial et al50 981 All spine cases 126 g (mean, Deep within Results: Increased IV
retrospective 1.13 g) wound rate of gram-
case series negative infections
compared with
historic controls (P
, 0.0001)
Limitations:
Retrospective
study; 14 patients
with cultures
negative for
seroma; no
standardization of
vancomycin dosing
Armaghani et al45 25 Pediatric spinal 1g Deep and Results: No deep IV
retrospective deformity superficial infections among
case series (idiopathic and within patients; no
neuromuscular) wound complications
Limitations: Case
series; no
comparison group
(continued )
BMI = body mass index

20 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Julia A. Katarincic, MD, et al

Table 2 (continued )
The Effect of Local Application of Vancomycin on Infection Rates in Patients Undergoing Spine Surgery
Results and
No. of Vancomycin Study Level of
Study/Type Patients Case Type Powder Dose Location Limitations Evidence

Hill et al51 300 Posterior spine 122 g Deep and Results: Significant III
retrospective surgery superficial decrease in deep
cohort within infection rate (P =
wound 0.0297) Limitations:
Retrospective
study; surgeons in
vancomycin group
and control group
were different
Martin et al52 306 Posterior fusion for 2g Deep and Results: No III
retrospective deformity superficial significant
cohort within difference in
wound infection rates
Limitations:
Retrospective study
Emohare et al53 303 Posterior thoracic 1g Deep and Results: No III
retrospective and lumbar surgery superficial infections among
cohort within the 96 patients
wound treated with
vancomycin; 7
infections among
207 patients in the
control group
Limitations:
Retrospective
study; no P values
calculated;
considerable
differences in
characteristics of
control and
treatment groups
Theologis et al54 215 Posterior fusion for 2g Deep within Results: Significant III
retrospective deformity wound decrease in
cohort infection rate (P =
0.01) Limitations:
Retrospective study

BMI = body mass index

who did not receive the powder.57
However, the procedures performed,
the dose of vancomycin, the defini-
tion of an SSI, and the study design
varied substantially among the
studies and may have muddled the
seemingly conclusive data. Despite
these concerns, there were no reports
of pseudarthrosis, renal failure, or
increased selection of gram-negative
organisms. One study did report that
14 of 981 patients developed a
postoperative seroma, although the
study authors were unable to relate
the seroma to the use of vancomycin
powder.50
A retrospective study compared the
use of systemic antibiotic prophylaxis
alone versus the use of standard
antibiotic prophylaxis with local
application of vancomycin powder
before wound closure in patients
undergoing open elbow contracture
release and hinged external fixator
placement.58 Among 272 patients,
the infection rate was 6.5% in the
control group and 0% in the van-
comycin powder group (P =
0.0027).58 Another recent study
evaluated the use of vancomycin
powder with staged definitive fixa-
tion for management of high-energy
periarticular tibial fractures.59 The
study included both open and closed
fractures, and among 93 patients
available for follow-up, only 10

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review
received vancomycin powder. No
difference in infection rates was
noted between patients who were
treated with vancomycin powder
and those who were not, but the
sample size was limited to 10
patients in the vancomycin group.
Although vancomycin powder
appears to be effective at decreasing
postoperative infections in spine sur-
gery, a large void remains in the evi-
dence for other orthopaedic
subspecialties. Randomized con-
trolled trials, particularly within the
fields of arthroplasty and trauma, are
needed to determine the efficacy of
local vancomycin powder for infec-
tion reduction.
Incisional Negative-pressure
Wound Therapy
INPWT aids in wound healing and
granulation tissue formation via
three mechanisms: increasing capil-
lary blood flow and fibrovascular
tissue ingrowth, decreasing edema
and wound tension, and promoting
wound contraction.60 In addition,
INPWT is thought to decrease local
inflammatory response and cell
death by increasing the oxygen gra-
dient across a wound.
In a multicenter, prospective, ran-
domized study of high-risk lower
extremity injuries, including tibial
plateau, pilon, and calcaneal frac-
tures, there was a significantly lower
rate of infection among those who
had an incisional wound vacuum
placed during surgery compared with
the control group (P = 0.049).61 The
relative risk of infection was 1.9
times higher in the control group.
In a 2013 review of 33 studies on
INPWT, 9 studies focused on
orthopaedic surgery, including
trauma surgery, foot and ankle sur-
gery, and arthroplasty.62 In all areas
except arthroplasty, Karlakki
et al62 found that patients who
received an incisional wound vac-
uum had a reduction in wound
22
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
drainage and incidence of infection.
In a study of INPWT used to pre-
vent seromas after total hip ar-
throplasty, seromas in patients
treated with INPWT were smaller
than in those treated with a stan-
dard dressing (1.97 mL with
INPWT versus 5.08 without
INPWT; P = 0.021).63 In a study
comparing wound healing after
total knee arthroplasty with post-
operative application of negative
pressure dressings or sterile gauze,
the authors noted the development
of blisters at the surgical site of 15
of 24 knees treated with INPWT
and no additional wound healing
benefit.64
Few data are available to support
the use of a wound vacuum in
uncomplicated primary arthroplasty,
but it may be beneficial in patients
undergoing arthroplasty for fracture
or in patients with increased wound
drainage postoperatively. However,
studies of INPWT after arthroplasty
have small patient cohorts; thus, it is
difficult to draw meaningful conclu-
sions regarding INPWT from the
available literature.65,66
INPWT is effective at decreasing
wound dehiscence and infection, but
conclusions regarding the duration of
use or optimal pressure to maximize
wound healing and minimize skin
complications are lacking. In addi-
tion, there are no data indicating
whether intermittent suction pro-
vides a clinical benefit over continu-
ous pressure settings. One study
compared the use of INPWT or sterile
dressing to decrease the rate of
wound complications after total
ankle arthroplasty.67 A wound vac-
uum set at 280 mm Hg was used in
the INPWT group for 6 or 7 days
(PICO; Smith and Nephew). The
authors noted that INPWT was an
independent predictor for avoiding
wound-healing issues, but there was
no difference in infection rates
among patients who received
INPWT or a sterile dressing.
Journal of the American Academy of Orthopaedic Surgeons
Fibrin Sealant and Occlusive
Dressings
The use of silver hydrogel dressings is
growing because of their antimicro-
bial, nonadherent, and absorptive
properties. Elemental silver provides
broad antimicrobial coverage against
several organisms, including yeast;
fungi; and aerobic, anaerobic, gram-
positive, and gram-negative bacteria.
In a moist environment, silver be-
comes ionized and interacts with
negatively charged molecules within
a bacterial cell, leading to disruption
in DNA replication.68
A 2014 study by Cai et al69 com-
pared Aquacel Ag (ConvaTec) sur-
gical dressings (n = 903) with a
standard gauze dressing (n = 875)
and demonstrated that the use of
silver dressings was an independent
factor for reduction of acute pros-
thetic joint infections that occurred
within 3 months of the initial surgery
(P = 0.005). Of note, the silver
dressings were left on for 5 days,
whereas the standard dressings re-
mained in place for only 2 days.
Another study of surgical dressings
in TJA found a decrease in wound
complications (P = 0.15), fewer
dressing changes, and higher patient
satisfaction among 262 patients
receiving an occlusive antimicrobial
dressing compared with a standard
surgical dressing.70
In a study of the efficacy of silver
sulfadiazine dressings in preventing
infection of external fixation pin
sites, 1% silver sulfadiazine dressings
were applied to the pin sites of 49
patients.71 Gauze dressings alone
were applied to the pin sites of 49
patients in the control group. The
rates of pin-tract infection were sig-
nificantly reduced in the sulfadiazine
dressing group compared with the
gauze dressing group (P = 0.01).
Silver dressings may further reduce
bacterial loads when combined with
INPWT, although more research on
this topic is needed.69

Cyanoacrylate glue is used in vari-
ous medical subspecialties, including
plastic surgery, dermatology, urol-
ogy, general surgery, and orthopae-
dic surgery. Although few studies in
the orthopaedic literature address
this product, it has been shown to
decrease wound drainage after total
knee arthroplasty and has been
shown to provide good tensile
strength when combined with a sub-
cuticular suture.72
Authors’
Recommendations for
Preventing SSI
On the basis of our review of the lit-
erature, we have developed a series of
recommendations for preventing
SSIs, including initiation of a MRSA
screening program before elective
surgery, either by nasal swab or PCR
to treat nasal carriage (Table 3). We
also advise instituting a chlorhex-
idine application training program
among staff in the preoperative area.
Patient alert systems and pre-
operative education can be used to
increase patient compliance with
chlorhexidine bathing protocols.
Proper use of sterile povidone-iodine
irrigation should include appropriate
dilution of the solution and retention
of the solution in the wound bed for
$3 minutes. This irrigation protocol
may reduce infection rates, but cur-
rently, only three studies on this
topic are available in the orthopaedic
literature.40,42,43
Summary
Infection remains a paramount con-
cern in orthopaedic surgery, and
conscious efforts must be made to
implement the most current evidence-
based treatment modalities to
decrease the incidence of post-
operative infections. On both indi-
vidual and institutional levels,
systems must be created to decrease
January 1, 2018, Vol 26, No 1
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Table 3
Authors’ Recommendations for Preventing Surgical Site Infections
Recommendation
MRSA screening
Chlorhexidine bathing
Adhesive draping
Povidone-iodine irrigation
Vancomycin powder
Incisional negative-pressure wound
therapy
Fibrin sealant/occlusive dressings
MRSA = methicillin-resistant Staphylococcus aureus, PCR = polymerase chain reaction
SSIs while recognizing that post-
operative infections are frequently
multimodal. The use of local vanco-
mycin powder, INPWT, and fibrin
sealants or silver adhesive dressings
may further reduce infection rates,
although additional research on these
options is required.
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References printed in bold type are
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