Tuberculous surgical site infections: Diagnosis, management, and prevention in the modern era

Tuberculosis surgical site infections (TB SSIs) represent a rare but significant complication in diverse surgical contexts, accounting for less than 1% of all TB cases. They present unique diagnostic and management challenges due to their insidious clinical course, which differs markedly from typical bacterial infections. TB SSIs arise either through direct inoculation of mycobacteria into surgical wounds or reactivation of latent TB at sites of surgical trauma. Risk factors include immunosuppression, malnutrition, and the presence of surgical implants. Clinical presentation is characterized by chronic, nonhealing wounds with minimal acute inflammation, often weeks to months after surgery. Diagnostic approaches include microbiological testing (acid-fast bacilli smear, mycobacterial culture, molecular tests), histopathological examination revealing granulomas, and supportive imaging. Intraoperative findings typically include granulomatous tissue, caseous necrosis, and well-formed sinus tracts. Management requires extended antitubercular therapy (9–12 months) combined with adequate surgical debridement and often removal of infected implants. With appropriate treatment, outcomes are generally favorable, with most patients achieving complete wound healing and infection resolution. Prevention strategies include preoperative TB screening in high-risk patients, rigorous sterilization protocols, careful allograft screening, and surveillance for unusual SSI patterns. Recent outbreaks linked to contaminated bone grafts highlight the importance of vigilance and robust tissue banking protocols. Early recognition and multidisciplinary management are essential for optimizing outcomes in these challenging infections.