Injury can lead to infection by (1) direct contamination of a sterile site with exogenous microorganisms; (2) disruption of the natural epithelial barriers of the gastrointestinal, respiratory, or gynecologic tracts, with contamination from endogenous microorganisms; (3) impairment of local antimicrobial clearance mechanisms by direct damage to tissue and the introduction of foreign bodies, seromas, or hematomas that act as adjuvants to promote infection; and (4) weakening of systemic host defenses through secondary mechanisms related to the consequence of injury.

Various pre-existing conditions may also contribute directly to the development of trauma-related infections through detrimental effects on local or systemic defense mechanisms. Examples include diabetes mellitus, obesity, malnutrition, advanced age, alcoholism, and single or multiple organ dysfunction. Hyperglycemia, hypoxemia, and hypothermia also increase the likelihood of developing a trauma-related infection. Importantly, the adequacy of the blood supply to the area of injury can affect the propensity to develop infection, and impaired perfusion because of pre-existing disease or perturbations due to the injury per se increases the risk of developing an infection. Necessary invasive and diagnostic interventions such as the placement of endotracheal tubes, intravascular catheters, and urinary catheters provide microorganisms with a portal of entry to sterile body sites, bypassing the normal defenses. These microorganisms may cause infection at the site of entry or may cause a distant infection following hematogenous dissemination of pathogens. Improper treatment can also predispose to infection by impairing the clearance of subpathologic concentrations of bacteria.

Efforts to prevent infection should begin immediately after injury. The general principles of initial management of injury include examination of external wounds to determine the extent and severity of injury and to identify foreign bodies, hematomas, damaged or devitalized tissue, and associated fractures. Wounds should be covered with a sterile dressing, preferably moistened with 0.9% normal saline, as soon as possible to prevent further contamination and tissue desiccation. Bleeding should be controlled by the application of direct pressure or by identification and ligation of bleeding points. Hematomas should be evacuated and injury to specialized tissues such as muscle, tendon, nerve, and blood vessels assessed. Debridement of all devitalized soft tissues, removal of foreign material, and control of bleeding are essential to proper wound management. The injury site should be irrigated with a physiologic solution such as 0.9% normal saline as soon as possible; however, this process should not impede definitive care or transfer to a trauma center.

In traumatic wounds associated with fractures, there is a direct relationship between the risk of infection and the severity of related soft-tissue injury. Early immobilization of the fracture reduces additional soft-tissue damage, limits hematoma formation, and can help decrease the risk of infection by preventing dissemination of contaminating bacteria.

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