Synopsis
Understand washout as structured source control rather than irrigation alone, preserve deep microbiology, match surgical access to anatomy, and connect empirical, directed and follow-up antimicrobial decisions to operative findings.
- Washout is a source-control package: adequate exposure, decompression, drainage, excision of non-viable tissue, representative sampling, dead-space management and a documented closure or re-look plan.
- Stable patients should provide blood and deep samples before antibiotics. Septic patients receive intravenous treatment after rapidly obtainable blood cultures even if theatre or aspiration is delayed.
- Take fluid before irrigation and multiple deep tissue samples with a fresh sterile instrument for each; five microbiology specimens are the BOASt standard for fracture-related and peri-prosthetic infection.
- Choose arthroscopic, open or image-guided access from joint, loculation, tissue state, implants, surgeon expertise and the need to debride bone or exchange components.
- Do not call a small incision and irrigation definitive when necrotic fascia, sequestrum, infected non-union or mature implant biofilm remains outside the field.
- Start empirical broad treatment after samples, review at 48 hours with preliminary culture results and narrow to organism, allergies, renal function, surgical strategy and local resistance.
- Failure to improve prompts repeat examination, culture review and imaging and often repeat washout; simply extending or broadening antibiotics does not sterilise retained pus or avascular tissue.
- Document postoperative weight-bearing, wound and drain plan, thrombosis prevention, analgesia, rehabilitation, laboratory monitoring and the named team responsible for culture follow-up.
Key red flags
Shock, rising lactate, altered consciousness or progressive organ dysfunction requires immediate sepsis antibiotics and emergency source control rather than prolonged diagnostic optimisation.
Necrotising features, compartment pressure, neurovascular compromise, rapidly spreading tissue change or gas demand radical exploration beyond a limited washout.
Persistent fever, pain, CRP rise, positive blood cultures or ongoing drainage after surgery indicates inadequate source control, another focus or ineffective therapy until investigated.
A prosthesis, fracture fixation, unstable bone, poor perfusion or major soft-tissue defect changes the operation and requires implant, vascular and reconstructive expertise rather than isolated lavage.
Investigation priorities
Identify systemic organisms before antibiotics when rapidly possible.
Management branches
Sepsis, necrotising infection, neurovascular threat or rapidly destructive closed-space infection is present.
- Take rapid blood cultures, start intravenous therapy and mobilise theatre and critical care concurrently.
- Expose the entire threatened anatomy, obtain deep samples and drain or excise all non-viable infected tissue.
- Restore perfusion, decompress compartments and stabilise unsafe bone with relevant specialist teams.
- Leave a documented re-look threshold and treat deterioration as incomplete source control.
The patient is stable and a deep infection operation can be deliberately designed.
- Withhold empirical antibiotics, review imaging, implants, union, perfusion and soft-tissue cover and agree the surgical endpoint.
- Take pre-irrigation fluid, five separate deep cultures and indicated histology before antimicrobials.
- Debride to viable tissue, manage dead space, implant stability and coverage and document any retained risk.
- Start empirical therapy after samples and review at 48 hours with preliminary culture results.