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

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Abstract
Background: Fracture-related infection (FRI) represents one of the most challenging complications in trauma care and disproportionately affects patients in low-resource settings, where diagnostic capacity, surgical infrastructure, and access to microbiology and reconstructive expertise are limited. Methods: An expert group was convened through the African Bone and Joint Infection Network (ABJIN) under the auspices of the European Bone and Joint Infection Society (EBJIS) and with support from the AO Alliance. Recommendations were developed through a three-step process: (1) a two-part survey assessing current practice and priority needs among clinicians from African countries, (2) an in-person multidisciplinary consensus meeting during the COSECSA Congress (Harare, 2024), and (3) an iterative collaborative review by a wider panel of clinicians from 14 countries. Results: The group produced context-adapted recommendations covering prevention, terminology, diagnosis, investigations, holistic patient optimization, antimicrobial therapy, local antibiotic delivery, and surgical management of FRI in low-resource settings. Key themes include the following: management of open fractures; diagnostic pathways prioritizing clinical criteria and intra-operative sampling; antimicrobial strategies reflecting local microbiology and drug availability; affordable local antibiotic carriers; and the importance of soft-tissue management, multidisciplinary collaboration, and centralization of complex cases. Barriers specific to low-resource settings – delayed presentation, restricted microbiology services, limited implant availability, and high burdens of comorbidities – were integrated into the recommendations. Conclusion: These consensus-based, context-specific recommendations provide practical guidance for FRI in low-resource settings. They aim to support clinicians in delivering safe, cost-effective care, accepting structural limitations while promoting standardization and audit. Further clinical research from low- and middle-income countries is needed to strengthen the evidence base and refine these recommendations.

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