Surgical Site Infection in Orthopedics in a Country with LimitedResources: Indications, Treatment and Results

Muluem OK¹, Nyankoue MF², Nyekel JR³, Elomo A², Tsiagadigui JG², Guemse ME² and Handy ED¹

¹Department of surgery, Yaounde General Hospital, Cameroon ²Department of surgery, Yaounde 1 University, Cameroon ³Department of surgery, Douala University, Cameroon

Abbrevations

DAIR: Debridement Antibiotic Implant Retention; DAIEX: Debridement Antibiotic Implant Exchange; DROM:

Debridement Removal of Osteosynthesis Material; DAIS: Debridement Antibiotic Implant Sterilisation; SSI: Surgical site infection; FLIPS: French-language Infectious Pathology Society; ROM: Removal of Osteosynthesis Material.

Introduction

Surgical Site Infection (SSI) in orthopaedics and Traumatology is defined as an infection occurring within 30 days of surgery, or within one year in the presence of implants, prostheses or prosthetic devices [1]. Their prevalence in sub-Saharan Africa varies between 9% and 12% [2, 3, 4, 5], yet according to the US National Research Council, the acceptable rate should be less than 5% [6]. SSI is a major concern for surgeons and one of the most dreaded surgical complications. Although relatively rare, SSI in orthopaedic surgery is often serious [7, 8]. When they do occur, they can call into question the benefits of an operation designed to improve function or repair the consequences of trauma, even if, in some cases, they are not life-threatening [9].

Although the diagnosis and identification of risk factors for SSI are easy, management is still difficult, depending on the context, and often requires rigorous treatment combining surgery and antibiotic therapy. In fact, in countries with limited resources, it is sometimes difficult for the patient to pay for all the laboratory biological tests, and sometimes the germ found is only sensitive to injectable antibiotics, increasing the length of hospital stay. The French Language Infectious Pathology Society (FLIPS) has defined recommendations for clinical practice with regard to osteoarticular infections on equipment [10].

Thanks to this work, they have proposed diagnostic and therapeutic approaches to osteoarticular infections on osteosynthesis equipment. Even though the protocols are well defined, their implementation remains a problem in developing countries, due to insufficient diagnostic means and lack of financial resources, as social security or health insurance is not accessible to the majority [11].

Despite this difficult context and working environment, some authors have taken an interest in the management of SSI in orthopaedics in sub-Saharan Africa, which has led to satisfactory results and improved patient prognosis. These include Handy D, et al. [12], Fokam, et al. [4], in Cameroon, Ayouba G, et al. [3] in Togo and Mba Mba C, et al. in Gabon [5]. The Handy, et al. study has the disadvantage of a small sample size (n=4 for 68 operated patients) and a 6-months follow-up, whereas the Fokam study focused solely on the prevalence and risk factors of SSI. F or this reason, we undertook this study, aimed at describing the different methods of treating SSI in orthopaedics-traumatology in the city of Yaounde, using a larger sample and presenting the results to improve the prognosis of these patients. We hypothesized that the treatment of SSI, according to recommendations, would improve patient prognosis in the short and medium term.

Discussion

This study reports on the surgical and medical management of SSI in a developing country. It is limited by its retrospective nature, which prevented us from recruiting a larger sample.

In our series, the median age of patients was 42.35 ± 13.37 years, with 66% being male. Many African authors have found similar results [3, 4, 5, 14]. This age group represents the proportion of patients more prone to trauma, surgery and SSI.

Patients had undergone fracture surgery in 92% of cases, of which 55% were open fractures, 37% closed fractures and 5% arthroplasty. The lower limb was the most frequent anatomical site at 97%, dominated by the leg at 46%. Indeed, road traffic accidents are the leading cause of trauma in developing countries requiring orthopaedic surgery. In addition to the risk factors associated with the working environment and the technical platform, factors such as skin opening and the complexity of fracture lines in the case of high-energy trauma increase the risk of infection [15, 16, 17]. These results are similar to those of Ngaroua, et al. [18], who found a frequency of 57.9% for open fractures, of which 40.6% involved the leg. Other authors such as Ide Garba. et al, Malick. et al, Madougou. et al, have also reported a predominance of SSI after osteosynthesis of fractures in the proportions 82.1% ;75.23%; and 88.72% respectively [2, 19, 20].

Diagnosis of SSI was primarily clinical, with local examination showing a skin fistula or discharge from the surgical wound in all cases. The aetiology was identified on bacteriological examination. Most of these clinical signs were related to deep infection, especially in the presence of an implant. These signs accounted for 89% in our study, rates comparable to those of Ide Garba et al, who found 85% deep infection in 2018 in Cotonou [2].

The main germs found were Staphylococcus aureus at 23.1%, Klebsiella Pneumoniae at 13.5% and Enterobacter cloacae at 12.5%, Escherichia coli at 10.6% and Pseudomonas aeruginosa at 8.7%. In 53.8% of cases, the infections were polymicrobial. Staphylococcus aureus is a commensal germ found on the skin and nostrils. It is the most frequent germ in orthopaedic SSIs, both in Africa [2, 3, 4, 5, 12, 21, 22] and in the West [23, 24, 25]. The association with other Gram-negative and Gram-positive germs is sometimes the result of hospital contamination (nosocomial infection). This is constant in other series but at different rates.

The antibiotics most prescribed after culture results were gentamicin (35.4%), amikacin (26.2%), imipenem (21.5%) and ciprofloxacin (20.0%). These results are similar to those of Ousmane A et al, who found the same sensitivity rates for the aminoglycosides tested (Amikacin 26.1%, Gentamicin 38.9%) (10). These results lay a problem ; As aminoglycosides can only be prescribed for less than 10 days, combination therapy with another molecule is often recommended [10].

The aim of treatment of infections on osteosynthesis equipment is to eradicate the infectious site, so as to obtain a pain-free, healed joint or bone [26]. According to the literature, there are four approaches to surgical treatment: definitive removal of the implant, debridement with the implant in place, debridement with one-stage implant replacement, and two-stage implant replacement [27, 28, 29].

Surgically, debridement was performed in all surgical patients with SSI, thus ensuring detersion of the infected site before antibiotics were prescribed. This is in line with recommendations for the management of SSI [29]. Implant retention was performed in 32% of cases, and implant replacement in 26%. This result is significantly lower than that of Rodham, et al. [30], who reported a 72.2% rate of DAIR in a retrospective study of the long-term outcome of the treatment of post-fracture limb osteitis.

In fact, the rate of early diagnosis of SSI and immediate surgical management is higher in Western countries, where the majority of patients are covered by social security, than in developing countries, where the diagnosis and treatment of SSI is sometimes delayed, contraindicating the DAIR technique. All other techniques, such as DAIEX, DROM and DAIS, were used in cases of late infection. DAIS is a new concept that we have developed in our working environment for hip prosthesis infections. Indeed, when DAIEX had to be performed, and in the event of difficulty in acquiring a new implant (prosthesis), we would remove the primary prosthesis and ensure its decontamination and sterilization; then re-implant it on the patient during the same operation. This technique prolonged operating time but enabled optimal debridement.

The median operating time was 60 minutes, with extremes of 45 and 150 minutes. These ranged from simple debridement to removal or replacement of osteosynthesis material. This operating time was significantly shorter than that of Zhou CH, et al. [31], who in a study published in Guangzhou in 2021 found an operating time of 124 min for one-stage treatment and 257 min for two-stage treatment. In addition, the two-stage procedure included an additional bone transfer procedure, which we did not include in our series.

In our study, the median hospital stay was 5 [2, 3, 4, 5, 6, 7, 8, 9, 10] days, with extremes of 2 and 30 days. This can be explained by the fact that patients treated with ROM were observed for 24 to 48 hours. Those treated with DAIR and DAIEX were hospitalized for 5 to 7 days, with extremes of 10 days. Longer hospital stays were mainly in patients with infectious recurrence, comorbidity, amputees and the financially constrained.

In the medium term, 66% of patients recovered without any sequelae. Nevertheless, this rate is lower than that reported by Rodham et al. and Hu Zhang et al., who found a cure rate of 75% and 92.5%, respectively [30, 32]. Indeed, there is an advent of multi-resistant germs in our hospitals, sometimes leading to the use of expensive antibiotics that are not accessible to all patients, which can influence compliance with treatment. What’s more, in Western countries, prescribing antibiotics for osteoarticular infections is a matter of concertation between infectiologists, biologists and orthopedists. The aim is to ensure that antibiotic therapy is properly administered and that the patient is cured [33]. Such concertation is rare in our environment, which may justify the recurrence rate of 14% in our study, whereas the cure rate is considered acceptable when recurrences are less than or equal to 5%.

Conclusion

SSI remains a worrying reality in orthopaedic and traumatology surgery departments in Yaounde. It requires early diagnosis and management to reduce the risk of recurrence and sequelae. Despite the above-average cure rate, much remains to be done in collaboration with other specialties to reduce the recurrence rate to an acceptable level. Primary and secondary prevention require compliance with asepsis rules, knowledge of SSI risk factors by all hospital personnel, and good compliance to avoid the advent of bacterial strains resistant to standard antibiotics.

Conflict of Interest

Advent.