Minimizing infection risk: fortune favors the prepared mind

Despite advances in care, infection in total joint arthroplasty remains a serious problem that has yet to be solved. Reported infection rates range from <0.5% in highly specialized centers to a high of 2% as reported at a national level. The epidemiology of total joint arthroplasty remains challenging because of the relatively low, but significant, incidence of infection. Still, there are variables that can be addressed that have demonstrated evidence regarding reduction in infection rates. These variables include optimizing medical conditions in the preoperative period such as anemia, blood glucose, and nutrition. In the perioperative period, administration of parenteral antibiotics within 1 hour of incision is a must. The effect of the operating room environment is less clear, but it is evident that traffic flow in the operating room has a negative effect on infection rates. Skin preparation with chlohexidine is now the agent of choice, and evidence exists that iodophor impregnated occlusive dressings add value. Razors should not be used. Surgical staples for closure have an increased risk of superficial infection as compared to subcuticular sutures. In the postoperative period, early, persistent wound drainage should be managed aggressively. There is no evidence to support the use of parenteral antibiotics past 24 hours in routine cases. Patients should be advised about prophylaxis for infection when undergoing dental work and other high-risk procedures. There is a strong movement to extend this prophylactic period indefinitely, as opposed to 2 years postoperatively. Finally, and perhaps most importantly, it is the surgeon's responsibility to be aware of all these issues and to strongly advocate for patient safety in ensuring that infection risk is minimized.