What are the best practices for preventing and managing secondary infections in older adults undergoing Split-Thickness Skin Grafting (SSG), considering their potential comorbidities and compromised immune systems?

Secondary Infection Prevention and Management Post-SSG in Older Adults

In older adults undergoing split-thickness skin grafting, secondary infections are rare but preventable through antimicrobial-impregnated dressings combined with negative-pressure wound therapy, which achieves 100% graft take without infection, even in high-risk elderly patients with multiple comorbidities. 1

Infection Risk Profile in Elderly SSG Patients

The actual infection risk in older adults post-SSG is remarkably low despite theoretical concerns:

• Only 1 infection occurred among 12 elderly patients (mean age 80.6 years) with severe comorbidities (mean Charlson Comorbidity Index of 7.1), representing an 8% infection rate 2
• Even in patients with dermatoporosis (chronic cutaneous fragility syndrome), donor sites healed successfully without requiring regrafting 2
• Zero infections were observed in a study of 25 multi-morbid patients (mean age 71.6 years) with high-risk factors including anticoagulation therapy, anemia, diabetes, and MRSA colonization when using composite collagen dressings 3

Optimal Prevention Strategy

Use antimicrobial-impregnated dressing (0.2% polyhexamethylene biguanide) combined with negative-pressure wound therapy immediately post-grafting:

• This combination achieved 100% graft take without any infections, hematomas, or seromas in chronic and contaminated wounds 1
• No secondary interventions were required in any patient using this approach 1
• The antimicrobial component provides broad-spectrum protection while NPWT ensures adequate immobilization and wound contact 1

Alternative High-Quality Dressing Option

For patients where NPWT is not feasible:

• Composite collagen/oxidized regenerated cellulose/silver-containing dressings provide excellent outcomes with zero infections observed during first dressing change at 10 days 3
• This approach achieved complete reepithelization in 10-34 days (mean 17.2 days) in elderly multi-morbid patients 3
• Particularly effective in patients on anticoagulation therapy, with minimal bleeding complications 3

Donor Site Management Considerations

For elderly patients at highest risk for delayed healing (severe comorbidities, dermatoporosis, poor nutritional status):

• Consider the "graft back" procedure where an additional split-thickness graft meshed 4:1 covers the donor site 4
• This converts an open wound to a covered wound, eliminating the secondary wound healing concern entirely 4
• Zero graft loss or graft infections occurred with this technique, with only 1 non-operative complication in 17 high-risk patients 4

Expected Healing Timeline

Manage expectations appropriately for elderly patients:

• 50% of elderly morbid patients heal donor sites within the normal 21-day range 2
• The remaining 50% require 25-97 days for complete healing, but all heal with local wound care alone without regrafting 2
• Prolonged healing does not equate to infection—it reflects age-related physiological changes 2

Critical Pitfalls to Avoid

• Do not assume prolonged healing equals infection—elderly patients with dermatoporosis commonly have extended healing times that resolve with conservative management 2
• Do not delay first dressing change beyond 10 days to allow early infection detection 3
• Inadequate immobilization and infection are the primary causes of graft failure—address both simultaneously with AMD-NPWT 1
• Graft thickness should remain between 0.010-0.014 inches even in elderly patients to balance donor site healing with graft success 2