New Guidelines Address Prevention of SSIs After Major Extremity Trauma

For most patients with major extremity trauma who are undergoing surgery, antibiotic prophylaxis with systemic cefazolin or clindamycin is recommended pre- and postoperatively to prevent surgical site infection (SSI), according to the recently published clinical practice guideline (CPG), Prevention of Surgical Site Infection After Major Extremity Trauma.

Patients with Type III open fractures, and potentially Type II open fractures, will generally require additional Gram-negative coverage, the CPG says.

This antibiotic prophylaxis recommendation is 1 of 5 in the CPG that are backed by strong evidence from the literature. The other recommendations with strong evidence:

The Prevention of Surgical Site Infection After Major Extremity Trauma CPG was developed through a collaboration between the American Academy of Orthopaedic Surgeons and the Major Extremity Trauma Research Consortium (METRC) and funded by a research grant from the US Department of Defense. It has also been endorsed by the American Shoulder and Elbow Surgeons.

In addition, AAOS and METRC collaborated on related Appropriate Use Criteria (AUC) to help healthcare professionals prevent SSIs in adults who have experienced major extremity trauma, defined as an open fracture, a major, high-energy closed fracture, a degloving injury, Morel lesions, low- and high-velocity gunshot injuries, a crush injury, a blast injury, or moderate- to high-energy force injuries.

This CPG includes 14 strong and moderate-strength recommendations for preoperative, perioperative, and postoperative interventions to decrease SSIs following major extremity trauma. It also offers options formulated with either low-quality evidence, no evidence, or conflicting evidence for the use of incisional negative pressure wound therapy for high-risk surgical incisions, the implementation of an orthoplastic team, patient outcomes related to the use of hyperbaric oxygen, preoperative skin preparation, and select modifiable and administrative risk factors.

The treatment scenarios provided by this AUC stem from the recommendation in the CPG issued by AAOS, detailed above. The AUC online tool provides clinicians algorithms on how to optimally evaluate the condition for patients presenting with high-energy extremity trauma who are being considered for surgical intervention. The AUC applies only to patients without the presence of SSI at the extremity trauma site.

The evidence-based CPG and AUC tools offer accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s specific clinical circumstances.


AAOS/METRC Prevention of Surgical Site Infection After Major Extremity Trauma Clinical Practice Guideline. Published March 21, 2022; accessed April 28, 2022. Available here.

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