Intraoperative and Postoperative Infection Prevention Karan Goswami, MD, MRCS a , Kimberley L. Stevenson, MD b , Javad Parvizi, MD, FRCS a, * a Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA b Department of Orthopaedics, University of Pennsylvania, Philadelphia, PA article info Article history: Received 18 October 2019 Received in revised form 29 October 2019 Accepted 29 October 2019 Keywords: prosthetic joint infection surgical site infection prevention hip and knee infection abstract Implementation of strategies for prevention of surgical site infection and periprosthetic joint infection is gaining further attention. We provide an overview of the pertinent evidence-based guidelines for infection prevention from the World Health Organization, the Centers for Disease Control and Preven- tion, and the second International Consensus Meeting on Musculoskeletal Infection. Future work is needed to ascertain clinical efficacy, optimal combinations, and the cost-effectiveness of certain measures. © 2019 Elsevier Inc. All rights reserved. Surgical site infection (SSI) and periprosthetic joint infection (PJI) carry an immense burden on healthcare providers and patients [1e3]. Infection is currently the leading cause of failure for primary and revision total knee (TKA) and total hip arthroplasty (THA) [4e6]. In addition to the healthcare cost implications, which are 4 times higher than for a typical primary total joint arthroplasty (TJA), there is considerable morbidity and mortality associated with PJI [7 ,8]. Multiple surgical interventions, prolonged hospitalization, and higher complication rates are typically encountered when managing patients with PJI [9e12]. Furthermore, with the increasing number of arthroplasties performed each year, the number of patients with PJI is predicted to rise to between 38,000 and 270,000 PJIs annually in the United States by the year 2030 [13, 14]. According to the conceptual formula for SSI risk proposed by the Centers for Disease Control and Prevention (CDC), SSIs are impacted by the number of microbes that contaminate an incision during surgery [15]. The source of pathogens for most SSI is often the endogenous flora of the patient’s skin, which can contain up to 2  10 6 bacteria/cm 2 [16, 17], while it takes as few as 100 microbes per gram of tissue to cause an SSI [18, 19]. Thus, preventive measures targeted at reducing the number of microorganisms at the surgical site are important for reducing SSI risk. Many perioperative, wound, and host factors have been asso- ciated with an increased risk of SSI and PJI. Therefore, a range of preventive measures have been proposed [20,21]. However, the most effective strategies for prevention of infection remain un- known. Host immunological variation, comorbid risk factors, dif- ferences in the type of surgery, and microbial virulence factors make infection prevention an ongoing challenge. Recent clinical practice guidelines from the CDC, World Health Organization (WHO), and the second International Consensus Meeting (ICM) on Musculoskeletal Infection have put forward evidence-based guidelines to help standardize the prevention of SSI and PJI [21e23]. This article highlights pertinent intraoperative and postoperative strategies that are either proven and evidence- based or deemed through expert consensus opinion to be effec- tive in reducing the risk of SSI and PJI. Intraoperative Measures Perioperative Antibiotic Prophylaxis Administration of prophylactic antibiotics during TJA has been demonstrated to be an important step in the prevention of SSI and This article is published as part of a supplement supported by an educational grant from OsteoRemedies, LLC. One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.10.061. * Reprint requests: Javad Parvizi MD, FRCS, Rothman Orthopaedic Institute,125 S 9th Street, Philadelphia, PA 19107. Contents lists available at ScienceDirect The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org https://doi.org/10.1016/j.arth.2019.10.061 0883-5403/© 2019 Elsevier Inc. All rights reserved. The Journal of Arthroplasty 35 (2020) S2eS8