A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence?

Bacterial profile of suction drains and the relationship thereof to surgical-site infections in prosthetic breast reconstruction

BACKGROUND

Despite the increasing popularity of prosthetic breast reconstruction, scant data exist on the microbiological profile of drainage fluid from closed-suction drains and the relationship thereof to surgical-site infections (SSIs) in breast reconstruction surgery. This study aimed to determine whether bacteria isolated from drainage fluid were associated with the development of SSIs, and whether the bacterial profile of drainage fluid could be a clinically useful predictor of SSIs.

METHODS

We performed a retrospective chart review of 61 women who underwent tissue expander/implant or direct-to-implant reconstructions. Patient demographics and culture studies of drainage fluid from suction drains collected on postoperative day 7 were evaluated.

RESULTS

Sixteen patients (26.23%) were culture-positive, and 45 patients (73.77%) were culture-negative. The most frequently isolated bacteria were coagulase-negative staphylococci, followed by Staphylococcus aureus. SSIs were diagnosed in seven patients and were mostly resolved by systemic antibiotics; however, the tissue expander or implant was explanted in two patients. Positive culture of drainage fluid from closed-suction drains was significantly associated with the development of SSIs (P<0.05). The positive predictive value was 37.50%, and the negative predictive value was 97.78%.

CONCLUSIONS

To our knowledge, this study is the first to demonstrate a significant association between the microbiological profile of drainage fluid from closed-suction drains and the development of SSIs in patients with prosthetic breast reconstructions. The high negative predictive value suggests that microbial testing of drainage fluid from closed-suction drains may have clinical utility. Further prospective studies with larger sample sizes are required to confirm our findings.

Surgical antibiotic prophylaxis use and infection prevalence in non-cosmetic breast surgery procedures at a tertiary hospital in Western Australia-a retrospective study

BACKGROUND

Surgical site infections (SSIs) are a common complication following breast surgery procedures, despite being considered a clean surgery. The prevalence of SSIs can be minimised with the appropriate use of antibiotic prophylaxis as outlined in the Australian Therapeutic Guidelines (eTG). The aims of this study were to evaluate adherence to the eTG for antibiotic prophylaxis in breast surgery procedures at a Western Australian teaching hospital following an update of the guidelines in 2014 and examine the impact of prophylactic antibiotics on SSI incidence and length of hospital stay.

METHOD

A retrospective cross-sectional study which reviewed medical records from a random sample of 250 patients selected from 973 patients who underwent breast surgical procedures between February 2015 and March 2017.

RESULTS

Overall adherence to current eTG occurred in 49.2% (123/250) of operations. Pre-operative and post-operative antibiotics were prescribed in 98.4% (246/250) and 11.2% (28/250) operations respectively. Adherence rates to three specific elements of the eTG (drug prescribed, drug dosage and timing of administration) were 91.6% (229/250), 53.6% (134/250) and 86.4% (216/250) respectively. For the 14.4% (36/250) patients with relevant drug allergies, there was zero adherence to the eTG. Overall recorded SSI prevalence was low at 5.2% (13/250). The mean length of stay in patients (2.3 ± 1.7 days) was not influenced by level of eTG adherence (p = 0.131) or SSIs (p = 0.306).

CONCLUSION

These data demonstrate a significant improvement in overall adherence to the eTG from 13.3% to 49.2% (p =  < 0.001). The level of detected SSIs in this study was low. Further improvement is necessary with respect to prescribing appropriate antibiotic dosages and for those with allergies.

Plasma Activation of a Breast Implant Shell in Conjunction With Antibacterial Irrigants Enhances Antibacterial Activity

BACKGROUND

Infection and capsular contracture are two of the most significant complications of breast-implant surgery. Both complications are associated with bacterial contamination of the implant surface. Plasma activation of the surface of a silicone breast implant changes its surface properties from water repelling (hydrophobic) to water absorbing (hydrophilic), thus making it possible for antibacterial irrigants to temporarily adsorb onto the implant surface.

OBJECTIVES

To support our hypothesis that by changing the surface properties we could render antibacterial irrigation more effective in inhibiting bacterial growth on a breast implant shell.

METHODS

An in vitro study using silicone discs cut from a textured silicone breast implant shell was performed by treating some of the discs with plasma activation and then exposing the discs to contamination with either Staphylococcus aureus or Pseudomonas aeruginosa and then variously treating the discs with 10% povidone iodine, Cefazolin, or Gentamicin. Bacterial contamination was verified and counted using contact plates as well as culture media.

RESULTS

Plasma activation changed the wetting properties of the disc's surface from hydrophobic to hydrophilic. Nonplasma activated contaminated discs demonstrated clear bacterial growth both in the untreated group and in the antibacterial-treated group. Combining antibacterial treatment with plasma activation resulted in complete inhibition of bacterial growth in each of the groups treated with antibacterial irrigants.

CONCLUSIONS

Combining plasma activation with topical antibacterial irrigants can inhibit the growth of bacteria on implant shell discs. By changing the properties of the surface from hydrophobic to hydrophilic, the adsorption of the antibacterial irrigants is enhanced.

Breast Implant Infections: An Update

Prosthetic breast implantation is a common surgical procedure for augmentation and reconstruction after mastectomy. The incidence of implant infection is 1% to 2.5% and is higher for reconstruction following mastectomy compared with augmentation. Most infections are caused by gram-positive pathogens, such as coagulase-negative staphylococci, Cutibacterium species, Staphylococcus aureus, and streptococci. Acute infections are usually associated with fever and breast pain, erythema, and drainage. Subacute infections may present with chronic pain, persistent drainage, failed healing of the incision site, or migration of the implant. Depending on severity of infection, patients are started on empiric intravenous or oral antibiotics and closely monitored.

The Role of Antibiotics in Breast Pocket Irrigation and Implant Immersion: A Systematic Review

Background:

The usage of antibiotics and antiseptics to washout the breast pocket, or to soak the breast implant during surgery, has come under scrutiny in recent times. Guidelines from the Centers for Disease Control and Prevention give no recommendation for or against the usage of antibiotics in this regard. They do however offer a weak recommendation for washing tissues with iodophor. This systematic review aims to investigate the efficacy and impact of such topical antibiotic or antiseptic usage in reducing infection rates.

Methods:

A systematic electronic search was performed on the PreMEDLINE, MEDLINE, EMBASE, and CENTRAL (Cochrane) databases from inception to April 2017. Reference search was performed manually through Scopus. Results of the searches were independently screened by 2 reviewers (A.F. and P.H.). Studies involving an implant or tissue expander, with appropriate controls were included. Meta-analyses were performed where possible and data summarized when not.

Results:

Three retrospective cohort studies were found to fit the review requirements. No randomized control trials were found. These studies covered a period of 1996–2010 for a total of 3,768 women undergoing augmentative surgery. The usage of antibiotics in pocket washout or implant immersion resulted in lower infection rates (RR = 0.52; P = 0.004; 95% CI = 0.34–0.81).

Conclusions:

There is a clinical benefit in using antibiotics for breast pocket irrigation and implant immersion. However, the quality of the evidence obtained in this review is low; hence, we recommend a randomized control trial for a higher level of evidence on this important issue.

The Impact of Closed Incision Negative Pressure Therapy on Postoperative Breast Reconstruction Outcomes

Background

Studies report that incision management with closed incision negative pressure therapy (ciNPT) may provide clinical benefits, including protecting surgical incisions, for postsurgical closed incisions (eg, orthopedic, sternotomy, and colorectal). This retrospective analysis compared postoperative outcomes in patients who received ciNPT versus standard of care (SOC) for incision management after breast reconstruction postmastectomy.

Methods

Patient demographics, chemotherapy exposure, surgical technique, ciNPT use, number of drains, time to drain removal, and 90-day postoperative complication rates were analyzed from records of 356 patients (ciNPT = 177, SOC = 179) with 665 closed breast incisions (ciNPT = 331, SOC = 334).

Results

Overall complication rate was 8.5% (28/331) in ciNPT group compared with 15.9% (53/334) in SOC group (P = 0.0092). Compared with the SOC group, the ciNPT group had significantly lower infection rates [7/331 (2.1%) versus 15/334 (4.5%), respectively; P = 0.0225], dehiscence rates [8/331 (2.4%) versus 18/334 (5.4%), respectively; P = 0.0178], necrosis rates [17/331 (5.1%) versus 31/334 (9.3%), respectively; P = 0.0070], and seroma rates [6/331 (1.8%) versus 19/334 (5.7%), respectively; P = 0.0106]. The ciNPT group required significantly fewer returns to operating room compared with the SOC group [8/331 (2.4%) versus 18/334 (5.4%), respectively; P = 0.0496]. Time to complete drain removal per breast for ciNPT versus SOC groups was 9.9 versus 13.1 days (P < 0.0001), respectively.

Conclusions

Patients who received ciNPT over closed incisions following postmastectomy breast reconstruction experienced a shorter time to drain removal and significantly lower rates of infection, dehiscence, necrosis, and seromas, compared with the SOC group. Randomized controlled studies are needed to corroborate the findings in our study.

Closed Incision Negative Pressure Therapy in Oncological Breast Surgery: Comparison with Standard Care Dressings

Background:

Negative pressure wound therapy was developed for treating wounds associated with unfavorable healing factors. The principles of the negative pressure wound therapy applied on clean and closed surgical incision originate the closed incision negative pressure therapy (ciNPT). We evaluated the use of ciNPT in the setting of oncological breast surgery.

Methods:

From January 1, 2015, to June 31, 2015, we prospectively selected 37 patients undergoing oncological breast surgery with a minimum of 4 risk factors. Seventeen patients (25 surgeries) voluntary tested ciNPT (ciNPT sample), whereas the remaining 20 (22 surgeries) chose conventional postsurgery dressing (Standard Care sample). Follow-up controls to evaluate postsurgical complications were performed on days 7, 14, 30, and 90. At 12 months, the quality of life, scar, and overall aesthetic outcomes were evaluated with specific questionnaires filled in by surgeon and patient. The Standard Care sample was investigated on risk factors associated with poor healing.

Results:

The ciNPT sample showed a significant prevalence of high risk factors, especially extensive undermining and bilateral surgeries, and a predominance of women under 65 years; only 1/25 (4%) surgical procedures was followed by complications. In the Standard Care sample, 10 of 22 surgeries (45%) were followed by complications. The difference in complication rate between the 2 samples was significant. The BIS (Body Image Scale) scores suggested that most patients were satisfied with their body image regardless of the type of dressing. All other questionnaire scores clearly vouched for a significant superiority of the ciNPT. Previous surgery ≤ 30 days emerged as the surgery-related high risk factor most frequently associated with postsurgery complications.

Conclusion:

The results of our study support the use of ciNPT in oncological breast surgery: it showed to be a well-tolerated, adaptable, and reliable dressing capable of reducing postsurgical complications and improving scar outcomes in patients presenting with high risk factors.

3D printed Polycaprolactone scaffolds with dual macro-microporosity for applications in local delivery of antibiotics

Advanced scaffolds used in tissue regenerating applications should be designed to address clinically relevant complications such as surgical site infection associated with surgical procedures. Recognizing that patient-specific scaffolds with local drug delivery capabilities are a promising approach, we combined 3D printing with traditional salt-leaching techniques to prepare a new type of scaffold with purposely designed macro- and micro-porosity. The dual macro/micro porous scaffolds of medical-grade polycaprolactone (mPCL) were characterized for their porosity, surface area, mechanical properties and degradation. The use of these scaffolds for local prophylactic release of Cefazolin to inhibit S. aureus growth was investigated as an example of drug delivery with this versatile platform. The introduction of microporosity and increased surface area allowed for loading of the scaffold using a simple drop-loading method of this heat-labile antibiotic and resulted in significant improvement in its release for up to 3 days. The Cefazolin released from scaffolds retained its bioactivity similar to that of fresh Cefazolin. There were no cytotoxic effects in vitro against 3 T3 fibroblasts at Cefazolin concentration of up to 100 μg/ml and no apparent effects on blood clot formation on the scaffolds in vitro. This study therefore presents a novel type of scaffolds with dual macro- and micro-porosity manufactured by a versatile method of 3D printing combined with salt-leaching. These scaffolds could be useful in tissue regeneration applications where it is desirable to prevent complications using local delivery of drugs.

Antibiotic Prophylaxis and Resistance in Surgical Site Infection After Immediate Tissue Expander Reconstruction of the Breast

BACKGROUND

A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics after hospital discharge for breast reconstruction. There is no clinical evidence that this practice reduces surgical site infection (SSI) after immediate tissue expander breast reconstruction. Furthermore, multiple studies have suggested that current antibiotic choices may not be appropriately covering the causative organisms of SSI.

METHODS

An institutional breast reconstruction database from January 2005 to December 2011 was queried to identify patients undergoing immediate tissue expander reconstruction of the breast. The bacteriology of the infection, prophylactic and empiric antibiotic use, and antibiotic sensitivities were analyzed.

RESULTS

In 557 cases of immediate tissue expander breast reconstruction performed in 378 patients, SSIs were diagnosed in 50 (9.0%) cases. Two hundred patients were given oral antibiotics at discharge; 178 did not receive antibiotics. Surgical site infection developed in 12.0% of patients given oral antibiotics and in 13.5% of those not receiving antibiotics (P = 0.67). Wound culture data were obtained in 34 SSIs. Twenty-nine had positive cultures. The most common offending organisms were methicillin-sensitive (11) and methicillin-resistant (6) Staphylococcus aureus. Despite increased use of postoperative prophylaxis over the years, SSI incidence remained unchanged. However, trends toward increased resistance of SSI organisms to the preoperative and postoperative prophylaxis agents were observed. When first-generation cephalosporins were used as prophylaxis, SSI organisms showed resistance rates of 20.5% (preoperative cefazolin) and 54.5% (postoperative cephalexin).

CONCLUSIONS

Administration of extended prophylactic antibiotics does not reduce overall risk of SSI after expander-based breast reconstruction but may influence antibiotic resistance patterns when infections occur. The organisms most commonly responsible for SSI are often resistant to cefazolin.

Efficacy of Vancomycin-based Continuous Triple Antibiotic Irrigation in Immediate, Implant-based Breast Reconstruction

Background:

Single irrigation of the peri-implant space with a cefazolin-based triple antibiotic solution is a routine antibiotic prophylaxis measure during implant-based breast augmentation and reconstruction. Cefazolin, however, is less efficacious against resistant Staphylococcus species, which are the predominant bacterial species isolated from the peri-implant space. Vancomycin is effective against resistant Staphylococcus species and may be a more appropriate prophylactic agent. The availability of single-injection long-acting anesthetic agents allows the novel use of the elastomeric infusion pump for continuous irrigation of antibiotic solution into the peri-implant space. The efficacy of continuous irrigation with a vancomycin-based solution is evaluated here.

Methods:

Study patients (N = 163; group 1) who underwent immediate, direct-to-implant breast reconstruction received continuous infusion of a vancomycin-based triple antibiotic solution. Patients also received a single injection of liposomal bupivacaine in the pectoralis major/minor muscles for pain control. A historic control group (N = 113; group II) received ropivacaine local anesthetic via the infusion pump and a single intraoperative irrigation of the peri-implant space with the vancomycin-based triple antibiotic solution. Incidence of postsurgical infection during the 6 weeks after surgery was compared between the groups.

Results:

Group I patients had a statistically significant lower incidence of infections (1.9%) than group II patients (6.4%) (P = 0.007). There were no vancomycin-related adverse effects.

Conclusions:

Continuous breast irrigation with a vancomycin-based triple antibiotic solution is a safe and effective accompaniment for immediate implant reconstruction. Use of intramuscular anesthetic injection for postoperative pain control allows the elastomeric infusion pump to be available for local tissue antibiotic irrigation.

Breast reconstruction with anatomical implants: A review of indications and techniques based on current literature

One important modality of breast cancer therapy is surgical treatment, which has become increasingly less mutilating over the last century. Breast reconstruction has become an integrated part of breast cancer treatment due to long-term psychosexual health factors and its importance for breast cancer survivors. Both autogenous tissue-based and implant-based reconstruction provides satisfactory reconstructive options due to better surgeon awareness of "the ideal breast size", although each has its own advantages and disadvantages. An overview of the current options in breast reconstruction is presented in this article.

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.

Is antibiotic prophylaxis in breast augmentation necessary? A prospective study

BACKGROUND

The role of prophylactic antibiotics in breast augmentation remains controversial. However, the majority of surgeons are administering antibiotics.

OBJECTIVE

To investigate the effect of antibiotic(s) use in the incidence of infection and capsular contracture following breast augmentation.

METHODS

From September 2004 to November 2010, 180 patients underwent primary bilateral breast augmentation. They were prospectively divided into two equal groups: in group A (n=90), no antibiotics were given and, in group B (n=90), only one intravenous dose of cephalosporin was administered during the induction of general anesthesia. Preoperative data included age, body mass index, smoking status, medical history and implant volume. All operations were performed by the same surgeon using the same surgical technique and implant type. No drains were used. Operative data included operative time and estimated blood loss. Patients were evaluated for complications such as infection, hematoma and capsular contracture. The study concluded when all of the patients underwent the one-year follow-up. The Student's t test was used to analyze the results.

RESULTS

All patients completed the study and both groups had similar demographic data. No differences in operative data were observed. The mean operative time was 35 min and the mean blood loss was found to be minimal. In group A, no implant infections were reported, while a wound infection that occurred was treated successfully with oral antibiotics. In group B, no implant or wound infection was noticed. No capsular contractures or hematomas were observed.

CONCLUSIONS

The number of patients who underwent primary breast augmentation without antibiotics (n=90) was insufficient to draw any definitive conclusions. However, the present prospective study demonstrated that prophylactic use of antibiotics in breast augmentation had no significant effect on infection and capsular contracture rates. Further randomized clinical trials, in combination with guidelines from aesthetic plastic surgery societies, appear to be warranted.

Infections in Cancer Patients with Solid Tumors: A Review

Solid tumors are much more common than hematologic malignancies. Although severe and prolonged neutropenia is uncommon, several factors increase the risk of infection in patients with solid tumors, and the presence of multiple risk factors in the same patient is not uncommon. These include obstruction (most often caused by progression of the tumor), disruption of natural anatomic barriers such as the skin and mucosal surfaces, and treatment-related factors such as chemotherapy, radiation, diagnostic and/or therapeutic surgical procedures, and the increasing use of medical devices such as various catheters, stents, and prostheses. Common sites of infection include the skin and skin structures (including surgical site infections), the bloodstream (including infections associated with central venous catheters), the lungs, the hepato-biliary and intestinal tracts, and the urinary tract, and include distinct clinical syndromes such as post-obstructive pneumonia, obstructive uropathy, and neutropenic enterocolitis. The epidemiology of most of these infections is changing with resistant organisms [MRSA, Pseudomonas aeruginosa, extended spectrum beta-lactamase (ESBL)-producing organisms] being isolated more often than in the past. Polymicrobial infections now predominate when deep tissue sites are involved. Conservative management of most of these infections (antibiotics, fluid and electrolyte replacement, bowel rest when needed) is generally effective, with surgical intervention being reserved for the drainage of deep abscesses, or to deal with complications such as intestinal obstruction or hemorrhage. Infected prostheses often need to be removed. Reactivation of certain viral infections (HBV, HCV, and occasionally CMV) has become an important issue, and screening, prevention and treatment strategies are being developed. Infection prevention, infection control, and antimicrobial stewardship are important strategies in the overall management of infections in patients with solid tumors. Occasionally, infections mimic solid tumors and cause diagnostic and therapeutic challenges.

Incidence of Methicillin-Resistant Staphylococcus aureus (MRSA) Carrier Status in Patients Undergoing Post-Mastectomy Breast Reconstruction

BACKGROUND

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) carriers and infections continues to rise. Some specialties have demonstrated a reduction in infection through appropriate screening and treatment.

OBJECTIVES

We sought to investigate the incidence of preoperative colonization, postoperative conversion, and whether this had any impact on outcomes in patients undergoing post-mastectomy breast reconstruction (BR).

METHODS

This is a prospective study of a series of 122 BR patients from a single surgeon from May 2013 to March 2015. Nasal swabs were obtained at preoperative and postoperative clinic visits. The incidence of preoperative and postoperative colonization, demographic, and clinical variables were analyzed and compared to complication rates within 90 days of surgery.

RESULTS

The incidence of MRSA colonization was 3.3% (n = 4) preoperatively and 4.1% (n = 5) postoperatively. One patient was positive at both time points, and 4 patients converted postoperatively. Preoperative or postoperative colonization with MRSA was not associated with any specific patient demographics. Hospital length of stay tended to be longer in patients colonized both preoperatively (2.8 days vs 1.6 days, P = .075) and postoperatively (2.8 days vs 1.8 days, P = .072). Postoperative colonization trended toward an increased incidence of any complication (80.0% vs 35.7%, P = .068) and was significantly associated with delayed wound healing (40.0% vs 4.8%, P = .035). Having a minor complication (P = .073) and implant exposure (P = .056) tended to be associated with postoperative carriers.

CONCLUSIONS

The incidence of MRSA in breast reconstruction patients is relatively low, yet complications rates are higher in those patients. Multicenter randomized trials should be conducted to determine if there is a role for preoperative screening and treatment of MRSA carriers.

LEVEL OF EVIDENCE

2 Risk.

Breast Reconstruction Following Cancer Treatment

BACKGROUND

About 8000 breast reconstructions after mastectomy are per - formed in Germany each year. It has become more difficult to advise patients because of the wide variety of heterologous and autologous techniques that are now available and because of changes in the recommendations about radiotherapy.

METHODS

This article is based on a review of pertinent articles (2005-2014) that were retrieved by a selective search employing the search terms "mastectomy" and "breast reconstruction."

RESULTS

The goal of reconstruction is to achieve an oncologically safe and aestically satisfactory result for the patient over the long term. Heterologous, i.e., implant-based, breast reconstruction (IBR) and autologous breast reconstruction (ABR) are complementary techniques. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. If post-mastectomy radiotherapy (PMRT) is not indicated, implant-based reconstruction with or without a net/acellular dermal matrix (ADM) is a common option. Complications such as seroma formation, infection, and explantation are significantly more common when an ADM is used (15.3% vs. 5.4% ). If PMRT is performed, then the complication rate of implant-based breast reconstruction is 1 to 48% ; in particular, Baker grade III/IV capsular fibrosis occurs in 7 to 22% of patients, and the prosthesis must be explanted in 9 to 41% . Primary or, preferably, secondary autologous reconstruction is an alternative. The results of ABR are more stable over the long term, but the operation is markedly more complex. Autologous breast reconstruction after PMRT does not increase the risk of serious complications (20.5% vs. 17.9% without radiotherapy).

CONCLUSION

No randomized controlled trials have yet been conducted to compare the reconstructive techniques with each other. If radiotherapy will not be performed, immediate reconstruction with an implant is recommended. On the other hand, if post-mastectomy radiotherapy is indicated, then secondary autologous breast reconstruction is the procedure of choice. Future studies should address patients' quality of life and the long-term aesthetic results after breast reconstruction.

Reducing implant loss rates in immediate breast reconstructions

UK best practice guidelines for oncoplastic breast reconstruction were published in 2012. Implant-based reconstruction quality indicator (QI) targets for readmission, return to theatre and implant loss rates were set at 5% by 3 months, along with guidance to achieve these targets. The aims of this study were to quantify complication rates following implant-based reconstruction before and after the implementation of the guidelines. A retrospective audit of 86 patients with 106 implants in the 12 months to June 2013 was performed, C1. Following institutional changes including reducing antibiotic usage, a prospective audit was performed on 89 patients with 105 implants to June 2014, C2. Extended follow-up of salvaged implants was also performed. Demographics were not significantly different between the two cohorts apart from smoking. Implant loss rates fell from 7.5%(C1) to 1.9%(C2), p = 0.054 but at the cost of an increase in the return to theatre rate (14.2%-18%, p > 0.05). The implant salvage rate increased from 47% in C1 to 89.5% in C2, however, 3 of the implants that were salvaged were lost in the long term giving an overall salvage rate of 82.4% in C2. While an implant loss rate of <5% at 3 months appears achievable with less antibiotic use, this was made possible by the institution of an aggressive readmission and salvage policy. We would question the QI standards for readmission and return to theatre for immediate implant-based breast reconstruction, given that our implant loss rate of 1.9% was achieved with a return to theatre rate of 18%.

Reducing infection risk in implant-based breast-reconstruction surgery: challenges and solutions

Implant-based procedures are the most commonly performed method for postmastectomy breast reconstruction. While donor-site morbidity is low, these procedures are associated with a higher risk of reconstructive loss. Many of these are related to infection of the implant, which can lead to prolonged antibiotic treatment, undesired additional surgical procedures, and unsatisfactory results. This review combines a summary of the recent literature regarding implant-related breast-reconstruction infections and combines this with a practical approach to the patient and surgery aimed at reducing this risk. Prevention of infection begins with appropriate reconstructive choice based on an assessment and optimization of risk factors. These include patient and disease characteristics, such as smoking, obesity, large breast size, and immediate reconstructive procedures, as well as adjuvant therapy, such as radiotherapy and chemotherapy. For implant-based breast reconstruction, preoperative planning and organization is key to reducing infection. A logical and consistent intraoperative and postoperative surgical protocol, including appropriate antibiotic choice, mastectomy-pocket creation, implant handling, and considered acellular dermal matrix use contribute toward the reduction of breast-implant infections.

Is antibiotic prophylaxis in breast augmentation necessary? A prospective study

Background

The role of prophylactic antibiotics in breast augmentation remains controversial. However, the majority of surgeons are administering antibiotics.

Objective

To investigate the effect of antibiotic(s) use in the incidence of infection and capsular contracture following breast augmentation.

Methods

From September 2004 to November 2010, 180 patients underwent primary bilateral breast augmentation. They were prospectively divided into two equal groups: in group A (n=90), no antibiotics were given and, in group B (n=90), only one intravenous dose of cephalosporin was administered during the induction of general anesthesia. Preoperative data included age, body mass index, smoking status, medical history and implant volume. All operations were performed by the same surgeon using the same surgical technique and implant type. No drains were used. Operative data included operative time and estimated blood loss. Patients were evaluated for complications such as infection, hematoma and capsular contracture. The study concluded when all of the patients underwent the one-year follow-up. The Student's t test was used to analyze the results.

Results

All patients completed the study and both groups had similar demographic data. No differences in operative data were observed. The mean operative time was 35 min and the mean blood loss was found to be minimal. In group A, no implant infections were reported, while a wound infection that occurred was treated successfully with oral antibiotics. In group B, no implant or wound infection was noticed. No capsular contractures or hematomas were observed.

Conclusions

The number of patients who underwent primary breast augmentation without antibiotics (n=90) was insufficient to draw any definitive conclusions. However, the present prospective study demonstrated that prophylactic use of antibiotics in breast augmentation had no significant effect on infection and capsular contracture rates. Further randomized clinical trials, in combination with guidelines from aesthetic plastic surgery societies, appear to be warranted.

Salvaging the Infected Breast Tissue Expander: A Standardized Multidisciplinary Approach

Background:

Infections of breast tissue expander (TE) are complex, often requiring TE removal and hospitalization, which can delay further adjuvant therapy and add to the overall costs of breast reconstruction. Therefore, to reduce the rate of TE removal, hospitalization, and costs, we created a standardized same-day multidisciplinary outpatient quality improvement protocol for diagnosing and treating patients with early signs of TE infection.

Methods:

We prospectively evaluated 26 consecutive patients who developed a surgical site infection between February 2013 and April 2014. On the same day, patients were seen in the Plastic Surgery and Infectious Diseases clinics, underwent breast ultrasonography with or without periprosthetic fluid aspiration, and were prescribed a standardized empiric oral or intravenous antimicrobial regimen active against biofilm-embedded microorganisms. All patients were managed as per our established treatment algorithm and were followed up for a minimum of 1 year.

Results:

TEs were salvaged in 19 of 26 patients (73%). Compared with TE-salvaged patients, TE-explanted patients had a shorter median time to infection (20 vs 40 days; P = 0.09), a significantly higher median temperature at initial presentation [99.8°F; interquartile range (IQR) = 2.1 vs 98.3°F; IQR = 0.4°F; P = 0.01], and a significantly longer median antimicrobial treatment duration (28 days; IQR = 27 vs 21 days; IQR = 14 days; P = 0.05). The TE salvage rates of patients whose specimen cultures yielded no microbial growth, Staphylococcus species, and Pseudomonas were 92%, 75%, and 0%, respectively. Patients who had developed a deep-seated pocket infection were significantly more likely than those with superficial cellulitis to undergo TE explantation (P = 0.021).

Conclusions:

Our same-day multidisciplinary diagnostic and treatment algorithm not only yielded a TE salvage rate higher than those previously reported but also decreased the rate of hospitalization, decreased overall costs, and identified several clinical scenarios in which TE explantation was likely.

Improving Antimicrobial Regimens for the Treatment of Breast Tissue Expander-Related Infections

Background:

Infectious complications in tissue expander (TE) breast reconstruction can be devastating and costly. Therefore, to optimize care, we examined patient’s demographics, microbiology of TE infections, and the efficacy of empiric antimicrobial regimens and thereafter generated an algorithm for the treatment of these complex infections.

Methods:

We retrospectively reviewed all patients who underwent TE breast reconstruction between 2003 and 2012 and analyzed those patients who developed a “definite” device-related infection leading to TE explantation and had a positive intraoperative culture.

Results:

A total of 3,082 patients underwent immediate breast reconstruction with TE. Of these, 378 patients (12.3%) developed an infection, 189 (6.1%) eventually proceed with explantation, and 118 (3.8%) had a positive intraoperative culture. Gram-positive organisms caused 73% of infections, and Gram-negative organisms caused 27% of infections. Narrow-spectrum empiric antimicrobials with predominantly Gram-positive coverage were deemed appropriate in only 62% of cases, and those with Gram-negative coverage were appropriate in 46%. Broad-spectrum antimicrobials were used in 47% of cases, mainly recommended by infectious disease specialists, and were considered appropriate in >90% of the occasions.

Conclusions:

Current empiric antibiotic regimens do not cover the vast spectrum of organisms causing TE infections. To increase the salvage rate of an infected TE, at the first sign of infection, in addition to benefiting with an infectious diseases consultation, empiric coverage with broad-spectrum antibiotics active against biofilm-embedded organisms should be administered.

Prosthetic Breast Reconstruction With Acellular Dermal Matrices: Achieving Predictability and Reproducibility

The use of acellular dermal matrices in the setting of prosthetic breast reconstruction has captured the attention of many plastic surgeons. The regenerative capacity of these materials has provided additional tissue support to the mastectomy skin flaps with the ultimate result of improving surgical and aesthetic outcomes. Despite the benefits, there remains a significant diversity with regard to outcomes with some surgeons reporting increased morbidity. The reasons for this are varied but ultimately related to differences in patient selection and surgical techniques. The purpose of this article is to provide strategies for using acellular dermal matrix to achieve success in a manner that is usually associated with outcomes that are predictable and reproducible.

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

BACKGROUND

Closed-suction drains, implants, and acellular dermal matrix (ADM) are routinely used in tissue expander-based immediate breast reconstruction (TE-IBR). Each of these factors is thought to increase the potential for surgical site infection (SSI). Although CDC guidelines recommend only 24 hours of antibiotic prophylaxis after TE-IBR, current clinical practices vary significantly. This study evaluated the difference in SSI between 2 different prophylactic antibiotic durations.

STUDY DESIGN

A noninferiority randomized controlled trial was designed in which TE-IBR patients received antibiotics either 24 hours postoperatively or until drain removal. The primary outcome was SSI, as defined by CDC criteria. Operative and postoperative protocols were standardized. Secondary endpoints included clinical outcomes up to 1 year and all implant loss, or reoperation.

RESULTS

There were 112 TE-IBR patients (180 breasts) using ADM who were randomized into 2 study arms, with 62 patients in the 24-hour group and 50 in the extended group. Surgical site infection was diagnosed in 12 patients in the 24-hour group and 11 in the extended group (19.4% vs 22.0%, p = 0.82). The extended group had 7 patients who required IV antibiotics and an overall implant loss in 7 patients (14.0%). The 24-hour group had 4 patients who required IV antibiotics, with 3 requiring removal (4.8%). Patients with diabetes, postoperative seroma, or wound dehiscence were all more likely to develop SSI (p < 0.02).

CONCLUSIONS

In a randomized controlled noninferiority trial, 24 hours of antibiotics is equivalent to extended oral antibiotics for SSI in TE-IBR patients. Additional multicenter trials will further assess this important aspect of TE-IBR postoperative care.

Acellular Dermal Matrix in Reconstructive Breast Surgery: Survey of Current Practice among Plastic Surgeons

Background:

Acellular dermal matrices (ADMs) in plastic surgery have become increasingly popular particularly for breast reconstruction. Despite their advantages, questions exist regarding their association with a possible increased incidence of complications. We describe a collective experience of plastic surgeons’ use of ADMs in reconstructive breast surgery using an internet-based survey.

Methods:

Members of the American Society of Plastic Surgeons were recruited through voluntary, anonymous participation in an online survey. The web-based survey garnered information about participant demographics and their experience with ADM use in breast reconstruction procedures. After responses were collected, all data were anonymously processed.

Results:

Data were ascertained through 365 physician responses of which 99% (n = 361) completed the survey. The majority of participants were men (84.5%) between 51 and 60 years (37.4%); 84.2% used ADM in breast reconstruction, including radiated patients (79.7%). ADM use was not favored for nipple reconstruction (81.5%); 94.6% of participants used drains, and 87.8% administered antibiotics postoperatively. The most common complications were seroma (70.9%) and infection (16%), although 57.4% claimed anecdotally that overall complication rate was unchanged after incorporating ADM into their practice. High cost was a deterrent for ADM use (37.5%).

Conclusions:

Plastic surgeons currently use ADM in breast reconstruction for both immediate and staged procedures. Of those responding, a majority of plastic surgeons will incorporate drains and use postoperative antibiotics for more than 48 hours.

Phenotypic and genotypic characterization of Staphylococci causing breast peri-implant infections in oncologic patients

Background

Staphylococcus epidermidis and S. aureus have been identified as the most common bacteria responsible for sub-clinical and overt breast implant infections and their ability to form biofilm on the implant as been reported as the essential factor in the development of this type of infections. Biofilm formation is a complex process with the participation of several distinct molecules, whose relative importance in different clinical settings has not yet been fully elucidated. To our knowledge this is the first study aimed at characterizing isolates causing breast peri-implant infections.

Results

Thirteen S. aureus and seven S. epidermidis causing breast peri-implant infections were studied.

Using the broth microdilution method and the E-test, the majority of the strains were susceptible to all antibiotics tested. Methicillin resistance was detected in two S. epidermidis. All strains had different RAPD profiles and were able to produce biofilms in microtitre plate assays but, while all S. aureus carried and were able to express icaA and icaD genes, this was only true for one S. epidermidis. Biofilm development was glucose- and NaCl-induced (5 S. aureus and 1 S. epidermidis) or glucose-induced (the remaining strains). Proteinase K and sodium metaperiodate treatment had different effects on biofilms dispersion revealing that the strains studied were able to produce chemically different types of extracellular matrix mediating biofilm formation.

All S. aureus strains harboured and expressed the atlA, clfA, FnA, eno and cna genes and the majority also carried and expressed the sasG (10/13), ebpS (10/13) genes.

All S. epidermidis strains harboured and expressed the atlE, aae, embp genes, and the majority (six strains) also carried and expressed the fbe, aap genes.

Genes for S. aureus capsular types 5 and 8 were almost equally distributed. The only leukotoxin genes detected were lukE/lukD (6/13).

Conclusions

S. aureus and S. epidermidis breast peri-implant infections are caused by heterogeneous strains with different biofilm development mechanisms.

Since the collagen adhesin (cna) gene is not ubiquitously distributed among S. aureus, this protein could have an important role in the cause of breast peri-implant infections.

Electronic supplementary material

The online version of this article (doi:10.1186/s12866-015-0368-x) contains supplementary material, which is available to authorized users.

Infections after breast surgery: potential ways to reduce infection rates

SUMMARY 

Breast infection rates are higher than expected for clean cases and are decreased with the use of prophylactic preoperative antibiotics. Surgical care bundles include evidence-based measures such as selection of preoperative antibiotics to cover skin flora, skin preparation, stopping antibiotics within 24 h, normothermia and hair removal. Glycemic control should be addressed but there is no additional benefit with tight control. Drain antisepsis provides a promising new approach to reducing infections in breast operations that use surgical drains. Other surgical disciplines have shown benefit with methicillin-resistant Staphylococcus aureus decolonization, vancomycin powder application and use of gentamicin-impregnated collagen plugs.

Breast surgery under local anesthesia: second-stage implant exchange, nipple flap reconstruction, and breast augmentation

Breast reconstruction can be performed safely with local anesthesia. Utilization of the star flap method in conjunction with tattooing successfully provides optimal aesthetic results without the need for an additional donor site. When tissue expander to silicon implant exchange is part of the operative plan, use of triple antibiotic irrigation as well as the Keller Funnel is recommended. Breast augmentation and breast augmentation-mastopexy can also be performed with good results under local anesthetic in a private operating room setting. All other operative conditions, including sterility and sound operative surgical techniques, should be the mainstay of any practice.