New Global Guidelines Tackle Bone Infections Where Surgeons Lack Everything

Every year, an estimated 1.8 million people worldwide develop a fracture-related infection, a devastating complication in which bacteria colonize broken bone and the hardware used to fix it. The burden falls hardest on patients in low-resource settings across Africa, where diagnostic laboratories, surgical infrastructure, implants, and reconstructive expertise are scarce. Now, an international team of orthopaedic surgeons, plastic surgeons, microbiologists, and infectious-disease specialists has published the first comprehensive, consensus-based guidelines specifically designed for managing these infections in hospitals that lack the resources assumed by existing international standards.

The work, published in the Journal of Bone and Joint Infection, was coordinated through the African Bone and Joint Infection Network under the auspices of the European Bone and Joint Infection Society, with support from the AO Alliance. Led by Loïc Fonkoué of Yaoundé General Hospital in Cameroon and Elizabeth Tissingh of King’s College London, the group spanned 14 countries, from Ethiopia and Malawi to Switzerland and the United Kingdom. Every member had direct experience treating bone and joint infections in resource-limited environments, a deliberate design choice meant to ensure the recommendations reflect clinical reality rather than idealized conditions.

The recommendations were built through a three-step process. First, two 34-item questionnaires were distributed to network members in November 2024, gathering responses from 86 clinicians in 22 countries about their current practice and their most urgent needs. Second, a one-day consensus meeting was held during the annual congress of the College of Surgeons of East Central and Southern Africa in Harare, Zimbabwe, in December 2024, where a draft document was agreed upon. Third, the wider panel conducted an iterative collaborative review from December 2024 to February 2025, revising recommendations until broad agreement was reached. Notably, the group did not use formal voting or evidence grading, acknowledging that the evidence base from low-income settings is too thin for such methods.

A central technical point of the guidance is terminology and diagnosis. The experts endorse the term fracture-related infection, or FRI, which supersedes older labels such as post-traumatic osteomyelitis and fracture-fixation-associated infection. Because it is impossible to reliably distinguish deep from superficial infection after a fracture, any surgical-site infection following a fracture is considered an FRI. Diagnosis should rest primarily on clinical criteria: sinus tracts, purulence, wound breakdown, and delayed or failed bone healing all warrant suspicion. This emphasis matters because late presentation is common in low-resource settings, and by the time patients arrive, the classic confirmatory signs are often the only reliable indicators available.

The guidelines are equally pragmatic about laboratory and imaging resources. Wound swabs and sinus tract samples are explicitly discouraged for microbiological culture, since they tend to grow skin commensals that do not represent the true pathogen. Instead, intra-operative tissue sampling is the diagnostic test of choice: five samples taken with separate clean instruments raise diagnostic yield to 97 percent, compared with 84 percent for three samples, though three samples are deemed acceptable under constraint. Routine X-rays should be prioritized over costly CT, MRI, or nuclear imaging, which are helpful but not essential. Histology offers a low-cost adjunct, with more than five neutrophils per high-power field considered significant, a technique accessible even in laboratories that mainly process malaria blood films.

Perhaps the most striking technical content concerns antibiotic strategy. Data from Cameroon and Nigeria show that Gram-negative bacteria account for 65.8 percent and 49 percent of fracture-related infections respectively, a markedly different profile from high-income countries where Staphylococcus aureus dominates. The experts therefore recommend empirical therapy combining a glycopeptide, such as vancomycin, with an agent active against Gram-negatives, such as amikacin or meropenem, with cefazolin plus gentamicin as a fallback. For definitive oral therapy, they favor bactericidal drugs with high oral bioavailability and good bone penetration, including rifampicin, fluoroquinolones, clindamycin, and fosfomycin, while cautioning against cephalosporins for oral use and against the rifampicin-clindamycin combination, which risks inducible resistance.

Local antibiotic delivery receives detailed attention because it demonstrably works: in a study of 433 confirmed infections, adding local antibiotics to definitive management cut failure rates from 18.3 percent to 10.3 percent. Polymethylmethacrylate cement, readily available and affordable across Africa, can be fashioned into spacers or beads, though it requires removal surgery and has poorer drug elution than absorbable calcium sulfate and composite ceramic carriers. The guidelines also flag a practical dilemma: rifampicin, the cornerstone of anti-biofilm therapy for implant retention, is often restricted to tuberculosis treatment programs in African countries. Encouragingly, evidence from the SOLARIO trial suggests that when local antibiotic carriers are used, as little as seven days of systemic therapy may suffice, a finding with major implications for adherence and antimicrobial stewardship.

On the surgical side, the recommendations preserve the universal principles of meticulous debridement of dead tissue until punctate bleeding appears, copious low-pressure saline irrigation without additives, and rigid fracture stabilization. But they also codify resource-adapted innovations. Where patients cannot afford a new implant, the group endorses debridement and implant sterilization, in which the removed hardware is re-sterilized and reused during the same operation. Debridement and implant retention is favored for early infections when fixation is stable, since implants are scarce. For dead-space management, options range from the induced-membrane Masquelet technique with cement to antibiotic-impregnated bone autografts and bone transport using external frames. The group also warns against prolonged vacuum-assisted dressings, citing evidence that negative pressure wound therapy more than doubles recurrence risk in fracture-related infection.

Prevention and system-level reform round out the guidance. Improved early management of open fractures, which can become infected in up to 52 percent of cases in some series, is identified as the single most effective strategy for reducing the disease burden, alongside WHO surgical safety checklists, engagement with community leaders and traditional bone setters to reduce treatment delays, and optimization of comorbidities including HIV, diabetes, anemia, and malnutrition. The recommendations have been packaged as the seventh ACTIONS guideline, part of the African Consensus for Trauma in Orthopaedics: National Standards series, and are available in English, French, and Portuguese to maximize uptake across the continent.

The authors are candid about the limitations: much of the guidance rests on expert consensus rather than trials conducted in the settings it targets, and urgent research priorities include building treatment networks, defining optimal antibiotic regimens and sampling protocols, and establishing supply chains for local antibiotic carriers and circular fixators. They call on ministries of health, clinicians, and industry to invest in training, reconstructive capacity, and diagnostics. The guidelines do not replace international standards, the authors stress; rather, they translate essential principles into feasible strategies for the hospitals where the burden of bone infection is greatest, while insisting that robust audit and locally generated evidence will be needed to refine them for the future.

Subject of Research: Consensus guidelines for managing fracture-related infection in low-resource settings in Africa

Article Title: Management of fracture-related infection in low-resource settings in Africa: recommendations and guidelines from an international expert group

Article References: Fonkoué, L., Tissingh, E. K., Marais, L. C., Malaba, M., Abrha, K., Ferguson, J., Morgenstern, M., Cornu, O., Laubscher, M., Buzisa Mbuku, R., Galiwango, G. W., Botman, M., Wojno, J., Majigo, M. V., Martin Jr., C., Harrison, W. J., Schade, A. T., Marenah, K., Nyamutora, M., … McNally, M. (2026). Management of fracture-related infection in low-resource settings in Africa: recommendations and guidelines from an international expert group. Journal of Bone and Joint Infection, 11(4), 401-411. https://doi.org/10.5194/jbji-11-401-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-401-2026

Keywords: fracture-related infection, osteomyelitis, low-resource settings, Africa, orthopaedic surgery, antibiotic stewardship, consensus guidelines, global health, surgical infection, open fractures, microbiology, AO Alliance