Are Prophylactic Postoperative Antibiotics Necessary for Immediate Breast Reconstruction? Results of a Prospective Randomized Clinical Trial

Adherence to best practice consensus guidelines for implant-based breast reconstruction: Results from the iBRA national practice questionnaire survey

INTRODUCTION

The 2008 National Mastectomy and Breast Reconstruction Audit demonstrated marked variation in the practice and outcomes of breast reconstruction in the UK. To standardise practice and improve outcomes for patients, the British professional associations developed best-practice guidelines with specific guidance for newer mesh-assisted implant-based techniques. We explored the degree of uptake of best-practice guidelines within units performing implant-based reconstruction (IBBR) as the first phase of the implant Breast Reconstruction Evaluation (iBRA) study.

METHODS

A questionnaire developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Simple summary statistics were calculated for each survey item to assess compliance with current best-practice guidelines.

RESULTS

81 units from 79 NHS Trusts completed the questionnaire. Marked variation was observed in adherence to guidelines, especially those relating to clinical governance and infection prevention strategies. Less than half (n = 28, 47%) of units obtained local clinical governance board approval prior to offering new mesh-based techniques and prospective audit of the clinical, cosmetic and patient-reported outcomes of surgery was infrequent. Most units screened for methicillin-resistant staphylococcus aureus prior to surgery but fewer than 1 in 3 screened for methicillin-sensitive strains. Laminar-flow theatres (recommended for IBBR) were not widely-available with less than 1 in 5 units having regular access. Peri-operative antibiotics were widely-used, but the type and duration were highly-variable.

CONCLUSIONS

The iBRA national practice questionnaire has demonstrated variation in reported practice and adherence to IBBR guidelines. High-quality evidence is urgently required to inform best practice.

Is single-stage implant-based breast reconstruction (SSBR) with an acellular matrix safe?: Strattice™ or Meso Biomatrix® in SSBR

Background

Acellular matrices (AM) might enable a direct single-stage breast reconstruction procedure resulting in an improved efficacy of the reconstruction phase for patients. Safety concerns are an important issue due to a recent study which shows that single-stage breast reconstruction with Strattice™ resulted in more complications versus a two-stage reconstruction. Therefore, the goal of this study is to compare the short- and long-term complications of a single-stage breast reconstruction with the use of two types of AM (Strattice™ and Meso Biomatrix®) versus two-stage breast reconstruction without the use of an AM.

Methods

Cohort study with single-stage breast reconstruction with Strattice™ (n = 28) or Meso BioMatrix® (n = 20) or two-stage breast reconstruction without an AM (n = 36) at the Maastricht Academic Hospital, the Netherlands. All complications, in particular major complications with the need for re-admission to the hospital, re-exploration, and implant explantation, were the primary outcome measures. A 1-year follow-up was achieved for all patients.

Results

Baseline characteristics of all 52 patients were similar between groups. There was a significantly higher complication rate in the single-stage AM groups with loss of the implant in 40.0% of the breasts from the Meso BioMatrix® group and in 10.7% of the Strattice™ group compared to no implant loss in the control group.

Conclusions

This cohort study clearly suggests that the use of a single-stage breast reconstruction is not safe with the use of these AMs. Well-designed prospective studies that guarantee the safety of those matrices should be published before these AMs are used in implant-based surgery.

Level of Evidence: Level III, risk / prognostic study.

Analysis of clinical management of infected breast implants and of factors associated to successful breast pocket salvage in infections occurring after breast reconstruction

OBJECTIVES

Considerable efforts have been devoted so far to improve salvage procedures of infected breast implants in absence of defined guidelines or validated clinical protocols. Within a cohort of prospectively recruited patients who underwent breast reconstruction, we performed a retrospective review of proven implant infections in order to describe factors contributing to management success.

METHODS

We collected data in 1293 consecutive patients who underwent two stage (expander+prosthesis) breast reconstruction with at least 12 months of follow-up. Demographic data, timing of infection, type of microorganism, intent of salvage, fate of the implant, type of antibiotic treatment and follow-up were recorded in a prospective data collection on clinical records.

RESULTS

Implant infections occurred in 103 of 1293 patients (8%). Among these, 73 (71%) were proven infections with confirmed microbiology. Implant pocket salvage was attempted in 43/73 (59%). patients A higher proportion of expander implant pockets were successfully saved compared to prosthetic pocket (p=0,04). Gram-positive microrganisms represented the majority of etiologic agents, with coagulase negative staphylococci prevailing over Staphylococcus aureus. No association was observed between success rate and type of infecting microorganism. A higher proportion of patients with previous or intraoperative radiotherapy or with perioperative chemotherapy underwent an attempt of implant salvage (p=0,081 and 0,0571 trend, respectively). No single antibiotic regimen was superior to the others in terms of success rate. Implant pocket salvage was higher in expanders compared to prostheses (74% vs 33% p=0,04). Higher success rates in implant pocket salvage were evident when implant replacement was preceded and followed by antibiotic treatment compared to inpatient antibiotic treatment alone (100% versus 57%, p=0,035).

CONCLUSION

Patient selection in clinical practice leads to differences in patients with breast implant infection who are considered for attempts at implant salvage vs. those who are treated with implant removal. Salvage of breast implant pockets can be obtained in the majority of patients with combined one-step implant replacement surgery and antibiotic treatment. Increased efforts and protocols to recruit patients into pocket salvage management are needed.

Prevalence and Predictors of Postdischarge Antibiotic Use Following Mastectomy

OBJECTIVE Survey results suggest that prolonged administration of prophylactic antibiotics is common after mastectomy with reconstruction. We determined utilization, predictors, and outcomes of postdischarge prophylactic antibiotics after mastectomy with or without immediate breast reconstruction. DESIGN Retrospective cohort. PATIENTS Commercially insured women aged 18-64 years coded for mastectomy from January 2004 to December 2011 were included in the study. Women with a preexisting wound complication or septicemia were excluded. METHODS Predictors of prophylactic antibiotics within 5 days after discharge were identified in women with 1 year of prior insurance enrollment; relative risks (RR) were calculated using generalized estimating equations. RESULTS Overall, 12,501 mastectomy procedures were identified; immediate reconstruction was performed in 7,912 of these procedures (63.3%). Postdischarge prophylactic antibiotics were used in 4,439 procedures (56.1%) with immediate reconstruction and 1,053 procedures (22.9%) without immediate reconstruction (P.05). CONCLUSIONS Prophylactic postdischarge antibiotics are commonly prescribed after mastectomy; immediate reconstruction is the strongest predictor. Stewardship efforts in this population to limit continuation of prophylactic antibiotics after discharge are needed to limit antimicrobial resistance. Infect Control Hosp Epidemiol 2017;38:1048-1054.

Do Prolonged Prophylactic Antibiotics Reduce the Incidence of Surgical-Site Infections in Immediate Prosthetic Breast Reconstruction?

BACKGROUND

Approximately 50,000 women in the United States undergo mastectomy and immediate prosthetic breast reconstruction annually, and most receive postoperative prophylactic antibiotics. The effect of these antibiotics on the risk of surgical-site infections remains unclear.

METHODS

The authors searched the Medline, Embase, and Cochrane Library databases for studies that compared less than 24 hours and greater than 24 hours of antibiotics following immediate prosthetic breast reconstruction. Primary outcomes were surgical-site infections and implant loss. Conservative random effects models were used to obtain pooled relative risk estimates.

RESULTS

The authors identified 927 studies, but only four cohort studies and one randomized controlled trial met their inclusion criteria. Unadjusted incidences of surgical-site infections were 14 percent with more than 24 hours of antibiotics, 19 percent with less than 24 hours of antibiotics, and 16 percent overall. Unadjusted incidences of implant loss were 8 percent with more than 24 hours of antibiotics, 10 percent with less than 24 hours of antibiotics, and 9 percent overall. The pooled relative risk of implant loss was 1.17 (95 percent CI, 0.39 to 3.6) with less than 24 hours of antibiotics, which was not statistically significant.

CONCLUSIONS

Prolonged antibiotic use did not have a statistically significant effect on reducing surgical-site infections or implant loss. There was significant heterogeneity between studies, and prolonged antibiotics may have increased the risk of implant loss in the randomized controlled trial. Definitive evidence may only be obtained with data from more prospective randomized controlled trials.

Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

Surgical site infection (SSI) after immediate breast reconstruction is much more common than would be expected after a clean surgical procedure. Although the SSI rates reported in individual studies are quite variable, there are no obvious explanations for the variation in infection rates between institutions. The microbiology of these SSIs is unusual, with higher proportions of infections caused by atypical Myobacterium species and Gram-negative bacilli than would be expected for this anatomic site. In an effort to prevent SSIs, many surgeons use a variety of different practices including irrigation and soaking of implants with antibiotic solutions and prolonged duration of prophylactic antibiotics, although the literature to support these practices is very sparse. In particular, prolonged use of antibiotics post-discharge is concerning due to the potential for harm, including increased risk of Clostridium difficile infection, development of antibiotic resistant organisms, and drug-related allergic reactions. With higher rates of mastectomy and breast implant reconstruction in women with early-stage breast cancer, including greater utilization of reconstruction in higher-risk individuals, the number of women suffering from infection after oncologic reconstruction will likely continue to increase. It is imperative that more research be done to identify modifiable factors associated with increased risk of infection. It is also essential that larger studies with rigorous study designs be performed to identify optimal strategies to decrease the risk of SSI in this vulnerable population.

Dressing Wear Time after Breast Reconstruction: A Randomized Clinical Trial

Background

The evidence to support dressing standards for breast surgery wounds is empiric and scarce.

Objective

This two-arm randomized clinical trial was designed to assess the effect of dressing wear time on surgical site infection (SSI) rates, skin colonization and patient perceptions.

Methods

A total of 200 breast cancer patients undergoing breast reconstruction were prospectively enrolled. Patients were randomly allocated to group I (dressing removed on the first postoperative day, n = 100) or group II (dressing removed on the sixth postoperative day, n = 100). SSIs were defined and classified according to criteria from the Centers for Disease Control and Prevention. Samples collected before placing the dressing and after 1 day (group I) and 6 days (both groups) were cultured for skin colonization assessments. Patients preferences and perceptions with regard to safety, comfort and convenience were recorded and analyzed.

Results

A total of 186 patients completed the follow-up. The global SSI rate was 4.5%. Six patients in group I and three in group II had SSI (p = 0.497). Before dressing, the groups were similar with regard to skin colonization. At the sixth day, there was a higher colonization by coagulase-negative staphylococci in group I (p<0.0001). Patients preferred to keep dressing for six days (p<0.0001), and considered this a safer choice (p<0.05).

Conclusions

Despite group I had a higher skin colonization by coagulase-negative staphylococci on the sixth postoperative day, there was no difference in SSI rates. Patients preferred keeping dressing for six days and considered it a safer choice.

Trial Registration

ClinicalTrials.gov NCT01148823