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Klifto KM, Rydz AC, Biswas S, Hultman CS, Erdmann D, Phillips BT. Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery. Plast Reconstr Surg 2023; 152:1154e-1182e. [PMID: 37141459 DOI: 10.1097/prs.0000000000010608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance. METHODS PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed. RESULTS The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence. CONCLUSIONS Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Affiliation(s)
- Kevin M Klifto
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery
| | | | - Sonali Biswas
- Division of Plastic and Reconstructive Surgery, University of Michigan School of Medicine
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Detlev Erdmann
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University School of Medicine
| | - Brett T Phillips
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University School of Medicine
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Stallard S, Savioli F, McConnachie A, Norrie J, Dudman K, Morrow ES, Romics L. Antibiotic prophylaxis in breast cancer surgery (PAUS trial): randomised clinical double-blind parallel-group multicentre superiority trial. Br J Surg 2022; 109:1224-1231. [PMID: 35932230 PMCID: PMC10364710 DOI: 10.1093/bjs/znac280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/08/2022] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Participants were patients with invasive breast cancer undergoing primary surgery. The aim was to test whether a single dose of amoxicillin-clavulanic acid would reduce wound infection at 30 days postoperatively, and to identify risk factors for infection. METHODS Participants were randomised to either a single bolus of 1.2 g intravenous amoxicillin-clavulanic acid after the induction of anaesthesia (intervention) or no antibiotic (control). The primary outcome was the incidence of wound infection at 30 days postoperatively. RESULTS There were 871 evaluable patients. Of these, 438 received prophylactic antibiotic and 433 served as controls. Seventy-one (16.2 per cent) patients in the intervention group developed a wound infection by 30 days, while there were 83 (19.2 per cent) infections in the control group. This was not statistically significant (odds ratio (OR) 0.82, 95 per cent c.i. 0.58 to 1.15; P = 0.250). The risk of infection increased for every 5 kg/m2 of BMI (OR 1.29, 95 per cent c.i. 1.10 to 1.52; P = 0.003). Patients who were preoperative carriers of Staphylococcus aureus had an increased risk of postoperative wound infection; however, there was no benefit of preoperative antibiotics for patients with either a high BMI or who were carriers of S. aureus. CONCLUSION There was no statistically significant or clinically meaningful reduction in wound infection at 30 days following breast cancer surgery in patients who received a single dose of amoxicillin-clavulanic acid preoperatively. REGISTRATION NUMBER N0399145605 (National Research Register).
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Affiliation(s)
- Sheila Stallard
- Gartnavel General Hospital, Gartnavel General Hospital, Glasgow, UK
| | - Francesca Savioli
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | | | - John Norrie
- Usher Institute, College of Medicine and Veterinary Medicine, Edinburgh, UK
| | | | - Elizabeth S Morrow
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Laszlo Romics
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK.,New Victoria Hospital, Glasgow, UK
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Woodfield JC, Clifford K, Schmidt B, Thompson‐Fawcett M. Has network meta-analysis resolved the controversies related to bowel preparation in elective colorectal surgery? Colorectal Dis 2022; 24:1117-1127. [PMID: 35658069 PMCID: PMC9796252 DOI: 10.1111/codi.16194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/28/2022] [Accepted: 05/11/2022] [Indexed: 01/01/2023]
Abstract
AIM There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs. METHOD A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines. RESULTS Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options. CONCLUSION While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs.
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Affiliation(s)
- John C. Woodfield
- Department of Surgical Sciences, Otago Medical School–Dunedin CampusUniversity of OtagoDunedinNew Zealand
| | - Kari Clifford
- Department of Surgical Sciences, Otago Medical School–Dunedin CampusUniversity of OtagoDunedinNew Zealand
| | - Barry Schmidt
- Department of Surgical Sciences, Otago Medical School–Dunedin CampusUniversity of OtagoDunedinNew Zealand
| | - Mark Thompson‐Fawcett
- Department of Surgical Sciences, Otago Medical School–Dunedin CampusUniversity of OtagoDunedinNew Zealand
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Lalla SC, Bonadurer GF, Murad MH, Brewer JD. Prophylactic antibiotics and Postoperative Surgical Site Infections in cutaneous surgery: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Antibiotic prophylaxis in breast surgery: a meta-analysis to identify the optimal strategy to reduce infection rates in breast surgery. Breast Cancer 2022; 29:945-956. [DOI: 10.1007/s12282-022-01387-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/07/2022] [Indexed: 11/25/2022]
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Prabhu N, McGuire C, Hong P, Bezuhly M. Patient Safety Initiatives in Cosmetic Breast Surgery: A Systematic Review. J Plast Reconstr Aesthet Surg 2022; 75:4180-4190. [DOI: 10.1016/j.bjps.2022.06.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/31/2022] [Accepted: 06/21/2022] [Indexed: 10/31/2022]
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Hart A, Furkert C, Clifford K, Woodfield JC. Impact of Incisional Surgical Site Infections on Quality of Life and Patient Satisfaction after General Surgery: A Case Controlled Study. Surg Infect (Larchmt) 2021; 22:1039-1046. [PMID: 34129403 DOI: 10.1089/sur.2021.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Most incisional surgical site infections (ISSI) are now diagnosed after discharge from hospital. In this context, it is important to document the impact ISSI has on our patients. Patients and Methods: Our surgical department sent a validated questionnaire to patients after they had been discharged. This documented incision problems, the 36-Item Short Form Health (SF-36) qualify of life questionnaire, and a patient satisfaction survey (PSS). We retrospectively reviewed records for 115 patients with an ISSI and 115 matched controls with no documented complications. Patient demographics and outcomes were collected. Differences in physical component summary (PCS) score and mental component summary (MCS) score and the PSS score were compared. Results: A majority (87%) of ISSIs were diagnosed after discharge from hospital. There were no differences in demographics, the American Society of Anaesthesiologists grade, or length of stay (LOS) between groups. Two months after surgery, ISSI was associated with lower post-operative SF-36 scores. The PCS was 42.9 (95% confidence interval [CI], 41.3-44.8) for ISSI cases and 47.0 (95% CI, 45.1-48.7) for controls (p ≤ 0.001). The MCS was 45.8 (95% CI, 43.7-47.9) and 50.2 (95% CI, 48.0-52.3), respectively (p = 0.01). Patients had less vitality, increased pain, and a reduction in physical activities and roles. The PSS score was 82.5 (95% CI, 79.6-85.4) in the control group and 74.1 (95% CI, 71.1-77.0) in the ISSI group (p < 0.001). Patients with ISSI reported worse satisfaction ratings with the quality of information received (p = 0.005) and their satisfaction with surgery (p < 0.001). Conclusions: Incisional surgical site infection was correlated with lower quality of life and PSS scores for up to two months after surgery. Prospective studies with pre-operative and post-operative quality of life are required to confirm causality.
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Affiliation(s)
- Alexander Hart
- Department of Surgical Sciences, Otago Medical School-Dunedin Campus Dunedin, Dunedin, New Zealand
| | - Chris Furkert
- Waitemata District Health Board, Takapuna, New Zealand
| | - Kari Clifford
- Department of Surgical Sciences, Otago Medical School-Dunedin Campus Dunedin, Dunedin, New Zealand
| | - John Campbell Woodfield
- Department of Surgical Sciences, Otago Medical School-Dunedin Campus Dunedin, Dunedin, New Zealand
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Gallagher M, Jones DJ, Bell‐Syer SV. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2019; 9:CD005360. [PMID: 31557310 PMCID: PMC6953223 DOI: 10.1002/14651858.cd005360.pub5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. This is an update of a Cochrane Review first published in 2005 and last updated in 2014. OBJECTIVES To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. SEARCH METHODS For this fourth update, in August 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. DATA COLLECTION AND ANALYSIS Three review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. We contacted study authors to obtain missing information. We evaluated the certainty of evidence using the GRADE approach. We used standard methodological procedures expected by Cochrane. MAIN RESULTS A total of 11 randomised controlled trials (2867 participants) were included in the review. No new studies were identified in this update. All studies included breast cancer patients and were based in the hospital setting. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with placebo or no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively probably reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85; moderate certainty evidence). Anticipated absolute effects were calculated for the outcome incidence of SSI; 105 per 1000 for the none or placebo group and 71 per 1000 (95% CI 56 to 89) for the preoperative antibiotic prophylaxis group. Analysis of the single study comparing perioperative antibiotic with no antibiotic was inconclusive for incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95; very low certainty evidence). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.Secondary outcomes were not consistently included in the studies investigating preoperative antibiotic prophylaxis. It is very uncertain whether there is a difference in incidence of adverse events between the treatment and no treatment or placebo groups (10 studies, 2818 participants); very low certainty evidence downgraded one level for serious risk of bias, one level for serious inconsistency and one level for serious imprecision. It is unclear whether there is a difference in time to onset of infection between the treatment and no treatment or placebo groups (4 studies, 1450 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. It is unclear whether there is a difference in rates of readmission to hospital between the treatment and placebo groups (3 studies, 784 participants); low certainty evidence downgraded one level for serious inconsistency and one level for serious risk of bias. It is unclear whether there is a difference in cost of care between the treatment and no treatment or placebo groups (2 studies, 510 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. No analysable secondary outcome data were reported for the single study evaluating perioperative antibiotics. AUTHORS' CONCLUSIONS Prophylactic antibiotics administered preoperatively probably reduce the risk of SSI in patients undergoing surgery for breast cancer. However, it is very uncertain whether there is an effect on incidence of adverse events. Furthermore, the effects on time to onset of infection, readmission to hospital and cost of care remain unclear. Further studies are required to establish the best protocols for clinical practice.
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Affiliation(s)
- Michael Gallagher
- Imperial College LondonDepartment of Surgery and Cancer, Faculty of MedicineSouth Kensington CampusLondonUKSW7 2AZ
| | - Daniel J Jones
- Hull UniversityHull York Medical SchoolCottingham RoadHullUKHU6 7RZ
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Woodfield J, Deo P, Davidson A, Chen TYT, van Rij A. Patient reporting of complications after surgery: what impact does documenting postoperative problems from the perspective of the patient using telephone interview and postal questionnaires have on the identification of complications after surgery? BMJ Open 2019; 9:e028561. [PMID: 31289081 PMCID: PMC6615906 DOI: 10.1136/bmjopen-2018-028561] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/27/2019] [Accepted: 06/12/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To identify the frequency of postoperative complications, including problems identified by patients and complications occurring after discharge from hospital. To identify how these impact on quality of life (QoL) and the patient's perception of the success of their treatment. DESIGN Data from three prospective sources: surgical audit, a telephone interview (2 weeks after discharge) and a patient-focused questionnaire (2 months after surgery) were retrospectively analysed. SETTING Dunedin Hospital, Dunedin, New Zealand. PARTICIPANTS Of the 500 patients, 100 undergoing each of the following types of surgeries: anorectal, biliary, colorectal, hernia and skin. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were complications and the 36-item Short Form Health Survey (SF-36). Secondary outcomes included the patient's ratings of their treatment and a questionnaire-derived patient satisfaction score. RESULTS 226 patients reported a complication; there were 344 separate complications and 411 reports of complications (16% of complications were reported on more than one occasion). The audit, telephone interview and questionnaire captured 12.6%, 36.3% and 51% of the 411 reports, respectively. Patients with complications had a lower SF-36 Physical Composite Summary (PCS) score (48.5 vs 43.9, p=0.021) and a lower Patient Satisfaction Score (85.6 vs 74.6, p<0.001). Rating of information received, care received, symptoms experienced, QoL and satisfaction with surgery were all significantly worse for patients with complications. On linear regression analysis, surgical complications, American Society of Anaesthesiologists score and age all made a similar contribution to the SF-36 PCS score, with standardised beta coefficients between 0.19 and 0.21. CONCLUSIONS Following surgery, over 40% of patients experienced complications. The QoL and satisfaction score were significantly less than for those without complications. The majority of complications were diagnosed after discharge from hospital. Taking more notice of the patient perspective helps us to identify problems, to understand what is important to them and may suggest ways to improve perioperative care.
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Affiliation(s)
- John Woodfield
- Department of Surgical Sciences, University of Otago, Dunedin, Otago, New Zealand
| | - Priya Deo
- Department of Surgical Sciences, University of Otago, Dunedin, Otago, New Zealand
| | - Ann Davidson
- Department of Surgical Sciences, University of Otago, Dunedin, Otago, New Zealand
| | - Tina Yen-Ting Chen
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Andre van Rij
- Department of Surgical Sciences, University of Otago, Dunedin, Otago, New Zealand
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Guo T, Chen B, Rao F, Wu P, Liu P, Liu Z, Li Z. Identifying the superior antibiotic prophylaxis strategy for breast surgery: A network meta-analysis. Medicine (Baltimore) 2019; 98:e15405. [PMID: 31027139 PMCID: PMC6831324 DOI: 10.1097/md.0000000000015405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The clinical roles of different antibiotic prophylaxis strategies for breast surgery remains large unknowns. The aim of this study is to evaluate different antibiotic prophylaxis strategies based on a network meta-analysis. METHODS We initially retrieved literature from globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating the antibiotic prophylaxis strategies for breast surgery. Relative postoperative infection rates were quantitatively pooled and estimated based on the Bayesian theorem. Values of surface under the cumulative ranking curve (SUCRA) probabilities were calculated and ranked. Additional pairwise meta-analyses were performed to validate differences between the respective strategies at the statistical level for further explanations. RESULTS After a detailed review, a total of 14 RCTs containing 6 different strategies were included for the network meta-analysis. The results indicated that the application of antibiotics administered during pre- plus post- plus intraoperative periods possessed the highest possibility of having the best clinical effects (SUCRA, 0.40), followed by intraoperative administration alone (SUCRA, 0.35) and pre- plus intraoperative administrations (SUCRA, 0.20). Moreover, an additional pairwise meta-analysis determined that pre- and intraoperative-related strategies significantly reduced postoperative infections at a statistical level. CONCLUSION Based on the current evidence, we concluded that application of antibiotics administered during pre- plus post- plus intraoperative periods seemed to reveal superior benefits. However, the essential roles of pure intraoperative and postoperative application were still need to be further validated.
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Affiliation(s)
- Tao Guo
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Baiyang Chen
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Fengying Rao
- School of Nursing, Huanggang Polytechnic College, Huanggang, P.R. China
| | - Ping Wu
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Pengpeng Liu
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Zhisu Liu
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Zhen Li
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
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Corcione S, Lupia T, De Rosa FG. Skin and soft tissue infections after breast surgery. Curr Opin Infect Dis 2019; 32:87-94. [PMID: 30695000 DOI: 10.1097/qco.0000000000000531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Breast surgery is considered a clean surgical procedure; nevertheless, infection rates are often higher than those reported after other similarly considered clean surgeries (e.g., thyroid, hernia). Acute bacterial skin and soft tissue infections, mostly surgical site infections and implant-associated infections are commonest events that could complicate postoperative care. RECENT FINDINGS Risk of infection is closely related to surgery procedure itself and patients host factors. Gram-positive bacteria with pattern of antimicrobial resistance are increasingly isolated and before today less frequent causes such as gram negative and mycobacteria infections. Impact of postoperative complications is underestimated and lacking an appropriate care and education for local and systemic management. SUMMARY We report the current evidence on the management of infections after breast surgery. New drugs options for methicillin-resistant Staphylococcus aureus and other gram positive should have a place in this setting. Stewardship activities aiming at reducing infections risks with the correct considerations of host, microbiological and surgical risk factors.
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Affiliation(s)
- Silvia Corcione
- Department of Medical Sciences, University of Turin, City of Health and Sciences, Turin, Italy
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Yang S, Liu G, Tang D, Cai D. Evaluation Intravenous Drip Cephazolin Prophylaxis of Breast Cancer Surgery Site Infection. J Craniofac Surg 2017; 28:e527-e531. [PMID: 28692521 DOI: 10.1097/scs.0000000000003780] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The efficacy of antibiotic prophylaxis for the prevention of surgical site infection (SSI) after breast cancer surgery remains uncertain. The authors of a recent Cochrane meta-analysis based on 15 randomized trials were unable to draw a definitive conclusion. The purpose of this study was to determine the effectiveness of prophylactic antibiotics for the prevention of SSI after breast cancer surgery and the risk factors for SSI. METHODS Breast cancer patients who underwent mastectomy at the authors' institution were enrolled in this study. All the patients give cephazolin by intravenous drip within 1 hour before surgery. Surgical site infection was defined using Centers for Disease Control criteria. Risk factors were abstracted from the electronic medical record. Pearson χ test, Student t test, and multivariable logistic regression were used for the analysis. RESULTS Four hundred fifty-eight patients undergoing mastectomy were enrolled in this study, including 293 with intravenous drip cephazolin and 165 without. Among them, an overall SSI rate of 6.1% was observed; 4.2% of patients without prophylactic antibiotics developed SSI compared with 7.2% with antibiotics (P = 0.210). Factors associated with SSI were hypertension, diabetes, length of stay (d), age, and length of stay. Weight, duration of surgery, No. of drains, surgical procedure, and type of breast disease were not associated with increased SSI rates. CONCLUSIONS Surgical site infection rates among patients who did and did not receive cephazolin after mastectomy had no significantly different. What is more, the authors should focus on advanced age, hypertension, diabetes, length of stay, and length of stay to decrease development of postoperative SSI rates.
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Affiliation(s)
- Sufang Yang
- Department of Pharmacy, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
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Garcia ES, Veiga DF, Veiga-Filho J, Cabral IV, Pinto NLL, Novo NF, Sabino Neto M, Ferreira LM. Antibiotic prophylaxis in reduction mammaplasty: study protocol for a randomized controlled trial. Trials 2016; 17:567. [PMID: 27899130 PMCID: PMC5129235 DOI: 10.1186/s13063-016-1700-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 11/14/2016] [Indexed: 11/10/2022] Open
Abstract
Background The role of antibiotics in surgical procedures where the risk of surgical site infection (SSI) is low remains uncertain. There is, to date, no evidence to justify the routine use of antibiotics in postoperative reduction mammaplasty. The aim of this study is to evaluate the effect of postoperative antibiotic treatment on the occurrence of SSI after breast reduction surgery. Methods This is a double-blind randomized clinical trial with 124 breast hypertrophy patients allocated to two treatment groups: antibiotic (n = 62) and placebo (n = 62). All patients will undergo reduction mammoplasty, performed by the same surgical team. The surgeons will raise the nipple-areola complex by the superomedial pedicle technique. The patients will receive antibiotics intravenously during anesthetic induction and every 6 hours thereafter during their 24-hour hospital stay. During discharge from the hospital, each patient will receive a numbered package containing either cephalexin or placebo capsules and will be directed to take one capsule every 6 hours for 7 days. Neither the surgery team nor the patients will know the contents of the capsules. Patients will be monitored for the occurrence of SSI once weekly during the first 30 days following hospital discharge by a single surgeon who is blinded to their treatment group. SSI will be evaluated based on the definition adopted by the Centers for Disease Control and Prevention. Discussion Due to the variety of risk factors for SSI and limited case studies, conclusions regarding the effect of antibiotics on the occurrence of SSIs following reduction mammaplasty are potentially biased. In recent studies, perioperative antibiotic prophylaxis was effective in preventing infection and is therefore recommended in clinical practice. However, antibiotic use in the postoperative period still remains controversial. Trial registration Clinicaltrials.gov Identifier: NCT02569866. Registered on 4 October 2015.
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Affiliation(s)
- Edgard Silva Garcia
- Translational Surgery Graduate Program, Federal University of São Paulo, Rua Napoleão de Barros, 725, 4th Floor, Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.,Division of Plastic Surgery, Universidade do Vale do Sapucaí, Rua Comendador José Garcia, 777, Centro, CEP: 37550-000, Pouso Alegre, MG, Brazil
| | - Daniela Francescato Veiga
- Translational Surgery Graduate Program, Federal University of São Paulo, Rua Napoleão de Barros, 725, 4th Floor, Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil. .,Division of Plastic Surgery, Universidade do Vale do Sapucaí, Rua Comendador José Garcia, 777, Centro, CEP: 37550-000, Pouso Alegre, MG, Brazil.
| | - Joel Veiga-Filho
- Division of Plastic Surgery, Universidade do Vale do Sapucaí, Rua Comendador José Garcia, 777, Centro, CEP: 37550-000, Pouso Alegre, MG, Brazil
| | - Isaías Vieira Cabral
- Division of Plastic Surgery, Universidade do Vale do Sapucaí, Rua Comendador José Garcia, 777, Centro, CEP: 37550-000, Pouso Alegre, MG, Brazil
| | - Natália Lana Larcher Pinto
- Division of Plastic Surgery, Universidade do Vale do Sapucaí, Rua Comendador José Garcia, 777, Centro, CEP: 37550-000, Pouso Alegre, MG, Brazil
| | - Neil Ferreira Novo
- Translational Surgery Graduate Program, Federal University of São Paulo, Rua Napoleão de Barros, 725, 4th Floor, Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil
| | - Miguel Sabino Neto
- Translational Surgery Graduate Program, Federal University of São Paulo, Rua Napoleão de Barros, 725, 4th Floor, Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil
| | - Lydia Masako Ferreira
- Translational Surgery Graduate Program, Federal University of São Paulo, Rua Napoleão de Barros, 725, 4th Floor, Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil
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14
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Surgical Site Infections in Breast Surgery: The Use of Preoperative Antibiotics for Elective, Nonreconstructive Procedures. Int J Breast Cancer 2016; 2016:1645192. [PMID: 27800185 PMCID: PMC5069355 DOI: 10.1155/2016/1645192] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/11/2016] [Accepted: 09/15/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Antibiotic prophylaxis for surgical site infections (SSIs) for breast surgery is widespread, but the benefit in clean surgical cases is not well defined. Methods. A retrospective analysis of 855 patients undergoing elective, nonreconstructive breast operations was performed, with 401 patients receiving no antibiotics and 454 patients receiving a single dose of preoperative antibiotic. Results. Administration of a preoperative antibiotic did not decrease the SSI rate. In this community-based study, antibiotic use practices varied considerably by surgeon. In univariate analyses, SSI rates appeared to increase with prophylactic antibiotic use (12% SSI with antibiotics versus 4% without, p < 0.0001), likely because the use of underdosed antibiotics was associated with higher rates of SSI (13.2% SSI with cefazolin 1 gram, p < 0.0001, and 15.4% SSI with clindamycin 300 mg or less, p = 0.0269). Methicillin-resistant Staphylococcus aureus was the most common isolate from SSI cultures, 31.8% (7 of 22). In multivariable analyses, increased risk of SSI was associated with BMI > 25 kg/m2 (OR: 1.08, 95% CI: 1.04-1.11, p < 0.0001). Conclusion. The administration of a single dose of preoperative antibiotic did not decrease the rate of SSI in this large series of patients undergoing clean breast operations. BMI >25 kg/m2 and the use of an inadequate dose of antibiotics for prophylaxis may increase risk of SSI.
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15
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Woodfield JC, Jamil W, Sagar PM. Incidence and significance of postoperative complications occurring between discharge and 30 days: a prospective cohort study. J Surg Res 2016; 206:77-82. [PMID: 27916378 DOI: 10.1016/j.jss.2016.06.073] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/15/2016] [Accepted: 06/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Accurate documentation of complications is fundamental to clinical audit and research. While it is established that accurate diagnosis of surgical site infection (SSI) requires follow-up for 30 days; for other complications, there are minimal data quantifying their importance between discharge and 30 days. METHODS In this prospective cohort study, inpatients undergoing general or vascular surgery were reviewed daily for complications by the medical team and a research fellow. A standardized telephone questionnaire was performed 30 days following surgery. All complications were documented and classified according to severity. RESULTS A total of 237 of 388 patients who completed the telephone survey developed a complication, including 77 who developed a complication for the first time after discharge from hospital. Overall 135 (33%) of a total of 405 complications were identified after discharge. These complications included 36 of 63 (57%) SSI, 6 of 12 small bowel obstructions, and three of four major thromboembolic events and a number of space SSI, urinary infections, functional gastrointestinal problems, and pain management problems. Cardiac, respiratory, and neurologic complications were mainly diagnosed in hospital. Of the 135 "postdischarge" complications, 89 were managed in the community and 46 (34%) resulted in admission to hospital, including seven which required a major intervention. There was one death. CONCLUSIONS One-third of complications occurred after discharge, and one-third of these resulted in readmission to hospital. Research and audit based on inpatient data alone significantly underestimates morbidity rates. Discharge planning should include contingency plans for managing problems commonly diagnosed after discharge form hospital.
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Affiliation(s)
- John C Woodfield
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand; The John Goligher Colorectal Surgical Unit, St James University Hospital, Leeds, United Kingdom.
| | - Wiqqas Jamil
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Peter M Sagar
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
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16
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Tacconelli E, Müller NF, Lemmen S, Mutters NT, Hagel S, Meyer E. Infection Risk in Sterile Operative Procedures. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:271-8. [PMID: 27159141 PMCID: PMC4985522 DOI: 10.3238/arztebl.2016.0271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 01/18/2016] [Accepted: 01/18/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The main objective of hospital hygiene and infection prevention is to protect patients from preventable nosocomial infections. It was recently stated that the proper goal should be for zero infection rates in sterile surgical procedures. In this article, we attempt to determine whether this demand is supported by the available literature. METHODS We systematically searched the Medline and EMBASE databases for studies published in the last 10 years on the efficacy of infection control measures and carried out a meta-analysis according to the PRISMA tool. We used the following search terms: "aseptic surgery," "intervention," "surgical site infection," "nosocomial infection," "intervention," and "prevention." RESULTS 2277 articles were retrieved, of which 204 were acquired in full text and analyzed. The quantitative analysis included 7 prospective cohort studies on the reduction of nosocomial infection rates after aseptic surgery. The measures used included training sessions, antibiotic prophylaxis, and operative-site disinfection and cleaning techniques. These interventions succeeded in reducing postoperative wound infections (relative risk (RR] 0.99 [0.98; 1.00]). Subgroup analyses on antibiotic prophylaxis (RR 0.99 [0.98; 1.01]) and noncontrolled trials (RR 0.97 [0.92; 1.02]) revealed small, insignificant effects. CONCLUSION A multimodal approach with the participation of specialists from various disciplines can further reduce the rate of postoperative infection. A reduction to zero is not realistic and is not supported by available evidence.
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Affiliation(s)
- Evelina Tacconelli
- German Center for Infection Research (DZIF), Department of Internal Medicine I, Medical University Hospital Tübingen
| | - Niklas F. Müller
- Division of Gastroenterology and Rheumatology, Department of. Internal Medicine, Neurology and Dermatology, University Hospital of Leipzig
| | - Sebastian Lemmen
- Central Department of Hospital Hygiene and Infectiology, Aachen University Hospital
| | - Nico T. Mutters
- Heidelberg University Hospital, Department of Infectious Diseases, Medical Microbiology and Hygiene
| | - Stefan Hagel
- Center for Infectious Diseases and Infection Control, Jena University Hospital
| | - Elisabeth Meyer
- Institute of Hygiene and Environmental Medicine, Charité—Universitätsmedizin Berlin
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17
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Jones DJ, Bunn F, Bell-Syer SV. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2014:CD005360. [PMID: 24609957 DOI: 10.1002/14651858.cd005360.pub4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. OBJECTIVES To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. SEARCH METHODS For this third update we searched the Cochrane Wounds Group Specialised Register (5 December 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We applied no language or date restrictions. SELECTION CRITERIA Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. DATA COLLECTION AND ANALYSIS Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. MAIN RESULTS A total of eleven studies (2867 participants) were included in the review. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. AUTHORS' CONCLUSIONS Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.
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Affiliation(s)
- Daniel J Jones
- Department of Health Sciences, University of York, Seebohm Rowntree Building, York, UK, YO10 5DD
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18
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Are Systemic Antibiotics Indicated in Aesthetic Breast Surgery? A Systematic Review of the Literature. Plast Reconstr Surg 2013; 131:1395-1403. [DOI: 10.1097/prs.0b013e31828bd752] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Habak JE, Varma S, Kiani M, Twaddle A, Emmerton LM. Prophylactic Antibiotic Use in Breast Cancer Surgery Patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2013. [DOI: 10.1002/j.2055-2335.2013.tb00229.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sheena Varma
- School of Pharmacy, Curtin Health Innovation Research Institute; Curtin University
| | | | | | - Lynne M Emmerton
- School of Pharmacy, Curtin Health Innovation Research Institute; Curtin University; Perth Western Australia
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20
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Thekkinkattil D. Efficacy of prophylactic antibiotic use in breast cancer surgery in obese patients. Gland Surg 2013; 2:54-5. [PMID: 25083458 DOI: 10.3978/j.issn.2227-684x.2013.05.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 05/08/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Dinesh Thekkinkattil
- Department of Oncoplastic Breast Surgery, Castle Hill Hospital, Castle Road, Cottingham, Hull, HU16 5JQ, United Kingdom
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21
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O'Connell RL, Rusby JE. Efficacy of prophylactic antibiotic administration for breast cancer surgery in overweight or obese patients: research highlight. Gland Surg 2013; 2:107-9. [PMID: 25083467 DOI: 10.3978/j.issn.2227-684x.2013.05.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 05/24/2013] [Indexed: 11/14/2022]
Abstract
The rate of surgical site infection (SSI) after breast surgery is higher than expected for a 'clean procedure'. There is currently no consensus on the use of antibiotics, and as a result there is variation in use. An infection may compromise cosmesis and delay the start of adjuvant therapy. This research highlight reviews a recent paper by Gulluoglu and colleagues investigating the use of antibiotics in overweight and obese patients undergoing breast cancer surgery and also reviews the current literature on this important topic.
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Affiliation(s)
- Rachel L O'Connell
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Down Road, Sutton, Surrey, SM2 5PT, UK
| | - Jennifer E Rusby
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Down Road, Sutton, Surrey, SM2 5PT, UK
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22
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Veiga DF, Veiga-Filho J, Damasceno CAV, Sales EML, Morais TB, Almeida WE, Novo NF, Ferreira LM. Dressing wear time after breast reconstruction: study protocol for a randomized controlled trial. Trials 2013; 14:58. [PMID: 23432779 PMCID: PMC3604956 DOI: 10.1186/1745-6215-14-58] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 02/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One of the major risk variables for surgical site infection is wound management. Understanding infection risk factors for breast operations is essential in order to develop infection-prevention strategies and improve surgical outcomes. The aim of this trial is to assess the influence of dressing wear time on surgical site infection rates and skin colonization. Patients' perception at self-assessment will also be analyzed. METHODS/DESIGN This is a two-arm randomized controlled trial. Two hundred breast cancer patients undergoing immediate or delayed breast reconstruction will be prospectively enrolled. Patients will be randomly allocated to group I (dressing removed on postoperative day one) or group II (dressing removed on postoperative day six). Surgical site infections will be defined by standard criteria from the Centers for Disease Control and Prevention (CDC). Skin colonization will be assessed by culture of samples collected at predefined time points. Patients will score dressing wear time with regard to safety, comfort and convenience. DISCUSSION The evidence to support dressing standards for breast surgery wounds is empiric and scarce. CDC recommends protecting, with a sterile dressing for 24 to 48 hours postoperatively, a primarily closed incision, but there is no recommendation to cover this kind of incision beyond 48 hours, or on the appropriate time to shower or bathe with an uncovered incision. The results of the ongoing trial may support standard recommendations regarding dressing wear time after breast reconstruction. TRIAL REGISTRATION ClinicalTrials.gov identifier: http://NCT01148823.
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Affiliation(s)
- Daniela Francescato Veiga
- Division of Plastic Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, Brazil.
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23
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Efficacy of Prophylactic Antibiotic Administration for Breast Cancer Surgery in Overweight or Obese Patients. Ann Surg 2013; 257:37-43. [DOI: 10.1097/sla.0b013e31826d832d] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Cabaluna ND, Uy GB, Galicia RM, Cortez SC, Yray MDS, Buckley BS. A Randomized, Double-blinded Placebo-controlled Clinical Trial of the Routine Use of Preoperative Antibiotic Prophylaxis in Modified Radical Mastectomy. World J Surg 2012; 37:59-66. [DOI: 10.1007/s00268-012-1816-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Sajid MS, Hutson K, Akhter N, Kalra L, Rapisarda IF, Bonomi R. An Updated Meta-Analysis on the Effectiveness of Preoperative Prophylactic Antibiotics in Patients Undergoing Breast Surgical Procedures. Breast J 2012; 18:312-7. [DOI: 10.1111/j.1524-4741.2012.01248.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Bunn F, Jones DJ, Bell-Syer S. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2012; 1:CD005360. [PMID: 22258962 DOI: 10.1002/14651858.cd005360.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. OBJECTIVES To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. SEARCH METHODS For this second update we searched the Cochrane Wounds Group Specialised Register (searched 31 August 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2008 to August Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 August 2011); Ovid EMBASE (1980 to 2011 Week 34); and EBSCO CINAHL (2008 to 25 August 2011). We applied no language or date restrictions. SELECTION CRITERIA Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. DATA COLLECTION AND ANALYSIS Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. MAIN RESULTS A total of nine studies (2260 participants) is included in the review. Eight studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.71, 95% confidence interval (CI) 0.53 to 0.94). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. AUTHORS' CONCLUSIONS Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, College Lane,Hatfield, Hertfordshire, AL10 9AB, UK.
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27
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Holmes DR. Ongoing consideration of cavity evaluation devices in the treatment of breast cancer. Ann Surg Oncol 2011; 18:1809-11. [PMID: 21519919 DOI: 10.1245/s10434-011-1684-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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28
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Abstract
Improvements in infection prevention practices over the past several decades have enhanced outcomes following aesthetic surgery. However, surgical site infections (SSI) continue to result in increased morbidity, mortality, and cost of care. The true incidence rate of SSI in aesthetic surgery is unknown due to the lack of a national surveillance system, but studies of SSI across surgical specialties have suggested that many of these infections are preventable. Patient-related factors-including obesity, glycemic control, and tobacco use-may contribute to the development of SSI following aesthetic surgery. In terms of SSI prevention, proper handwashing and surgical skin preparation are integral. Furthermore, the administration of prophylactic antibiotics has been shown to reduce SSI following many types of surgical procedures. Unfortunately, there are few large, randomized studies examining the role of prophylactic antibiotics in aesthetic surgery. The authors review the medical literature, discuss the risks of antibiotic overutilization, and detail nonpharmacological methods for reducing the risk of SSI.
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Affiliation(s)
- Michael A Lane
- Infectious Diseases Division, Washington University School of Medicine, St. Louis, Missouri, USA.
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29
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30
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Mekako AI, Chetter IC, Coughlin PA, Hatfield J, McCollum PT. Randomized clinical trial of co-amoxiclav versus no antibiotic prophylaxis in varicose vein surgery. Br J Surg 2009; 97:29-36. [DOI: 10.1002/bjs.6849] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Wound infection rates of up to 16 per cent are reported following varicose vein surgery and the value of antibiotic prophylaxis in clean surgery remains unclear.
Methods
Some 443 patients undergoing varicose vein surgery randomly received a single prophylactic dose of 1·2 g co-amoxiclav (219 patients) or no antibiotic (224). Patients completed a wound diary on postoperative days 3, 5, 7, 9 and 10 using an adapted ASEPSIS method of wound assessment, and were reviewed after 14 days.
Results
Patients who had prophylaxis had lower ASEPSIS wound scores on days 3, 5 and 7 (P = 0·043, P = 0·032 and P = 0·003 respectively), and lower total ASEPSIS scores (median (interquartile range) 3 (0–9) versus 6 (0–15); P = 0·013). They were less likely to consult their general practitioner (16.0 versus 24·3 per cent; P = 0·040) or to receive postoperative antibiotics (4·7 versus 13·5 per cent; P = 0·002) for wound-related problems. Wound outcomes were worse with higher body mass index (odds ratio (OR) 0·92 (95 per cent confidence interval (c.i.) 0·87 to 0·97); P = 0·005) and current smoking (OR 0·5 (0·3 to 0·9); P = 0·033). Prophylactic antibiotics conferred satisfactory wound healing (OR 2·2 (95 per cent c.i. 1·3 to 3·6); P = 0·003).
Conclusion
Antibiotic prophylaxis reduced wound-related problems after varicose vein surgery. Registration number ISRCTN12467340 (http://www.controlled-trials.com).
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Affiliation(s)
- A I Mekako
- Academic Vascular Surgery Unit, Alderson House, Hull Royal Infirmary, Hull HU3 2JZ, UK
| | - I C Chetter
- Academic Vascular Surgery Unit, Alderson House, Hull Royal Infirmary, Hull HU3 2JZ, UK
| | - P A Coughlin
- Academic Vascular Surgery Unit, Alderson House, Hull Royal Infirmary, Hull HU3 2JZ, UK
| | - J Hatfield
- Academic Vascular Surgery Unit, Alderson House, Hull Royal Infirmary, Hull HU3 2JZ, UK
| | - P T McCollum
- Academic Vascular Surgery Unit, Alderson House, Hull Royal Infirmary, Hull HU3 2JZ, UK
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31
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Paajanen H, Hermunen H. Does Preoperative Core Needle Biopsy Increase Surgical Site Infections in Breast Cancer Surgery? Randomized Study of Antibiotic Prophylaxis. Surg Infect (Larchmt) 2009; 10:317-21. [DOI: 10.1089/sur.2008.078] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hannu Paajanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Heikki Hermunen
- Department of Radiology, Central Hospital of Mikkeli, Mikkeli, Finland
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32
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Yiannakopoulou EC. Methodological issues regarding safety evaluation in randomized controlled trials of the effectiveness of antibiotic prophylaxis for the prevention of post-operative wound infection: systematic review. J Antimicrob Chemother 2009; 63:843-5. [PMID: 19240072 DOI: 10.1093/jac/dkp030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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33
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Willsher PC, Hall JL, Hall JC. Assessing wound morbidity after breast surgery using telephone interviews and postal questionnaires. ANZ J Surg 2008; 78:519. [PMID: 18522586 DOI: 10.1111/j.1445-2197.2008.04555.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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34
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Clinical Research in Breast Surgery: Reduction and Postmastectomy Reconstruction. Clin Plast Surg 2008; 35:215-26. [DOI: 10.1016/j.cps.2007.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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35
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Cunningham M, Bunn F, Handscomb K. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2006:CD005360. [PMID: 16625637 DOI: 10.1002/14651858.cd005360.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between three and 15%, higher than average for a clean surgical procedure. Pre and peri-operative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no current consensus on prophylactic antibiotic use in breast cancer surgery. OBJECTIVES To determine the effects of prophylactic antibiotics on the incidence of surgical site infection after breast cancer surgery. SEARCH STRATEGY We searched the Cochrane Wounds and Breast Cancer Groups Specialised Registers, the Cochrane Central Register of Controlled Trials (CENTRAL) issue 1 2006. MEDLINE 2002-2005, EMBASE 1980-2005, NRR issue 1 2005, CINAHL 1982-2004 and SIGLE 1976-2004. Companies and experts in the field were contacted and reference lists were checked. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials of pre and peri-operative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were, incidence of breast wound infection and adverse reactions to treatment. DATA COLLECTION AND ANALYSIS Two authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. MAIN RESULTS Six studies met the inclusion criteria. All six evaluated pre-operative antibiotic compared with no antibiotic or placebo. Pooling of the results demonstrated that prophylactic antibiotics significantly reduce the incidence of surgical site infection for patients undergoing breast cancer surgery without reconstruction (pooled RR 0.66, 95% CI, 0.48 to 0.89). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. AUTHORS' CONCLUSIONS Prophylactic antibiotics reduce the risk of surgical site infection in patients undergoing surgery for breast cancer. The potential morbidity caused by infection, such as delays in wound healing or adjuvant cancer treatments must be balanced against the cost of treatment and potential adverse effects such as drug reactions or increased bacterial resistance. Further studies of patients undergoing immediate breast reconstruction would be useful as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.
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Affiliation(s)
- M Cunningham
- Mount Vernon Hospital, Lymphoedema Clinic, Room 4, Main Outpatients, Mount Vernon Hospital, Northwood, Middlesex, UK, HP6 2RN.
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