Introduction.

In Sub-Saharan Africa, the orthopaedic surgeon is handling increasing numbers of trauma cases due to increasing road traffic accidents [1]–[3]. Additionally the African orthopaedic surgeon is faced with the HIV/AIDS epidemic, with increasing numbers of HIV infected patients, many of whom do not yet show symptoms, and have not yet started antiretroviral therapy (ART) [4]. The prevalence of HIV in the general population in Sub-Saharan Africa ranges from 3%–12% [5], while the prevalence of HIV infection among patients requiring orthopedic surgery ranges from 3.6% to 16% [6], [4]. The higher rates of 16% seen in Africa are probably due to the large numbers of young people vulnerable to trauma after road traffic accidents. This age group also has a higher HIV prevalence.

Surgery is considered clean if it is conducted in uncontaminated or uninfected tissues and the respiratory, gastrointestinal and genitourinary systems are not opened [7]. Without concomitant disease, such as HIV, surgical operations have less than 2% risk for post operative surgical site infections [8]–[10]. It has been postulated that in patients infected with HIV, the risk of postoperative infection is increased due to the decline in the number of CD4 cells [11]. Untreated HIV causes a gradual decline in CD4 counts with subsequent increase in opportunistic infections. It may also lead to an increase in the incidence of infection after surgery. It is expected that the risk reduces once the patient is on ART and the CD4 counts rise. Surgery in orthopaedics sometimes requires the insertion of implants of various biomaterials to replace a joint surface or to stabilise bone fragments. The use of implants is associated with an increase in the risk of postoperative infection [10]. Because a foreign body is implanted in the body which provides an area for possible colonisation by microbes, there is not only an increase risk of infections occurring in the first one month (early infection) following surgery, but also up to one year postoperatively (late infection). Infected implants are usually managed by antibiotics for long durations and removal or exchange of the implant all resulting in great morbidity and cost [12], [13].

Presently there is conflicting data on whether HIV or reduced CD4 count due to HIV increases the likelihood of infections in clean implant surgery [14]–[17], [7]. The dilemma about not knowing whether implant surgery is safe for HIV positive individuals, has led surgeons to believe that the risk of infection in HIV infected patients is too high. They avoid elective surgery and only consider emergency surgery [18]. This means that, with one in every six patients requiring orthopedic surgery being infected with HIV, denying this group of patients elective surgery leaves a large number of HIV infected patients who may be denied surgery based on an unsubstantiated risk of increased infection leading to reduced quality of life for these patients. With most large hospitals in East Africa performing about 7 implant orthopaedic surgeries a day, this could mean that about 300 patients a year in each of these hospitals may be denied elective surgery and suffer reduced quality of life [4], [19].

According to several American and European guidelines, prophylactic antibiotics should be started within one hour of the incision and stopped within 24 hours after the end of the operation [20]–[22]. By following these current protocols for implant surgery, the risk of post-operative infection has been greatly reduced [23]. In clean implant orthopedic surgery we can expect an infection rate of less than 2% [8], [9].

Though there are guidelines on the perisurgical management of patients undergoing implant surgery, none specifically address the HIV infected patient. Therefore there is need to develop guidelines for the orthopedic surgeon working in areas of high prevalence of HIV. Our study aims to gather the best evidence available on the risk of infection after clean implant orthopedic surgery in patients with HIV compared to patients without HIV to support the development of these guidelines.

We have conducted a systematic literature review to determine firstly, the incidence of post-operative surgical site infections in patients with HIV undergoing clean implant orthopedic surgery compared to patients without HIV. Secondly, we identified studies that evaluated the effect of the enhanced measure of prolonged antibiotic use compared to antibiotics given for up to 24 hours (standard care in most countries) in reducing the risk of post-operative infection in HIV infected patients.

Abstract.
Background.

There is dilemma as to whether patients infected with the Human Immunodeficiency Virus (HIV) requiring implant orthopaedic surgery are at an increased risk for post-operative surgical site infection (SSI). We conducted a systematic review to determine the effect of HIV on the risk of post-operative SSI and sought to determine if this risk is altered by antibiotic use beyond 24 hours.

Methods.

We searched electronic databases, manually searched citations from relevant articles, and reviewed conference proceedings. The risk of postoperative SSI was pooled using Mantel-Haenszel method.

Results.

We identified 18 cohort studies with 16 mainly small studies, addressing the subject. The pooled risk ratio of infection in the HIV patients when compared to non-HIV patients was 1.8 (95% Confidence Interval [CI] 1.3–2.4), in studies in Africa this was 2.3 (95% CI 1.5–3.5). In a sensitivity analysis the risk ratio was reduced to 1.4 (95% CI 0.5–3.8). The risk ratio of infection in patients receiving prolonged antibiotics compared to patients receiving antibiotics for up to 24 hours was 0.7 (95% CI 0.1–4.2).

Conclusions.

The results may indicate an increased risk in HIV infected patients but these results are not robust and inconclusive after conducting the sensitivity analysis removing poor quality studies. There is need for larger good quality studies to provide conclusive evidence. To better develop surgical protocols, further studies should determine the effect of reduced CD4 counts, viral load suppression and prolonged antibiotics on the risk for infection.