Efficacy of Prophylactic Antibiotic Administration for Breast Cancer Surgery in Overweight or Obese Patients: A Randomized Controlled Trial

PLGA and PDMS-based in situ forming implants loaded with rosuvastatin and copper-selenium nanoparticles: a promising dual-effect formulation with augmented antimicrobial and cytotoxic activity in breast cancer cells

Breast cancer is among the most prevalent tumors worldwide. In this study, in-situ forming implants (ISFIs) containing rosuvastatin calcium were prepared using three types of poly (D, L-lactic-co-glycolic acid) (PLGA), namely, PLGA 50/50 with ester terminal and PLGA 75/25 with ester or acid terminal. Additionally, polydimethylsiloxane (PDMS) was added in concentrations of 0, 10, 20, and 30% w/v to accelerate matrix formation. The prepared ISFIs were characterized for their rheological behaviors, rate of matrix formation, and in-vitro drug release. All the prepared formulations revealed a Newtonian flow with a matrix formation rate between 0.017 and 0.059 mm/min. Generally, increasing the concentration of PDMS increased the matrix formation rate. The prepared implants' release efficiency values ranged between 46.39 and 89.75%. The ISFI containing PLGA 50/50 with 30% PDMS was selected for further testing, as it has the highest matrix formation rate and a promising release efficiency value. Copper-selenium nanoparticles were prepared with two different particle sizes (560 and 383 nm for CS1 and CS2, respectively) and loaded into the selected formulation to enhance its anticancer activity. The unloaded and loaded implants with rosuvastatin and copper-selenium nanoparticles were evaluated for their antibacterial activity, against Gram-positive and negative microorganisms, and anticancer efficacy, against MCF-7 and MDA-MB-231 cell lines. The results confirmed the potency of rosuvastatin calcium against cancer cells and the synergistic effect when loaded with smaller particle sizes of copper-selenium nanoparticles. This formulation holds a considerable potential for efficient breast cancer therapy.

A Comparative Analysis of Prophylactic Antibiotic Administration in Emergency Surgery Versus Elective Surgery: A Comprehensive Review

Surgical site infections (SSIs) contribute to increased patient morbidity, prolonged hospital stays, and substantial healthcare costs. Prophylactic antibiotics play a pivotal role in mitigating the risk of SSIs, with their administration being a standard practice before both emergency and elective surgeries. This paper provides a comprehensive review and comparative analysis of the benefits of prophylactic antibiotic administration in emergency surgery versus elective surgery. Through a systematic literature review and analysis of relevant studies identified through PubMed searches, this paper highlights the specific benefits of prophylactic antibiotics between emergency and elective surgeries. The findings underscore the importance of tailored antibiotic regimens and administration protocols to optimize patient care and promote successful surgical outcomes in diverse clinical settings. Further research is warranted to refine guidelines and enhance understanding of the relationship between prophylactic antibiotics and surgical outcomes across different surgical contexts.

Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery

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.

Antibiotic prophylaxis in breast cancer surgery (PAUS trial): randomised clinical double-blind parallel-group multicentre superiority trial

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).

Preoperative antibiotic prophylaxis in mastectomy: A retrospective comparative analysis of 1413 patients with breast cancer

BACKGROUND AND OBJECTIVE

The reported rate of surgical site infections (SSIs) in breast cancer surgery varies widely in previous literature. The use of antibiotic prophylaxis is controversial but recommended by several guidelines. The aim of this study was to evaluate the efficacy of routine antibiotic prophylaxis in patients with breast cancer undergoing mastectomy.

METHODS

In this retrospective single-institution study, we reviewed 1413 consecutive female breast cancer patients who underwent mastectomy and/or axillary lymph node surgery between years 2012 and 2019. Prophylactic antibiotics for all patients undergoing mastectomy was introduced in our hospital in 2016 and before that the prophylaxis was prescribed individually on surgeons' preference. All patient records for 30 postoperative days were evaluated in detail and all SSIs were recorded. The rate of SSIs was compared between patients who received antibiotic prophylaxis and those who did not. A multivariate logistic regression model was used to define the odds ratio (OR) for the efficacy of antibiotic prophylaxis.

RESULTS

A total of 335 patients underwent mastectomy without antibiotic prophylaxis and 1078 with prophylaxis. The rate of SSIs was 6.9% in patients who received prophylaxis and 6.3% in patients without prophylaxis (p = 0.70). The rate of SSIs was similar before and after the introduction of regular antibiotic prophylaxis and there was no difference in any of the patient subgroups investigated. In multivariable logistic regression analysis, the OR for antibiotic prophylaxis was 1.04 (95% CI: 0.62-1.73, p = 0.88).

CONCLUSIONS

Routine use of antibiotic prophylaxis did not reduce the rate of SSIs in mastectomy. Unselective antibiotic prophylaxis for all patients does not seem mandatory in mastectomy.

A review on the anesthetic management of obese patients undergoing surgery

There has been an observed increase in theprevalence of obesity over the past few decades. The prevalence of anesthesiology related complications is also observed more frequently in obese patients as compared to patients that are not obese. Due to the increased complications that accompany obesity, obese patients are now more often requiring surgical interventions. Therefore, it is important that anesthesiologists be aware of this development and is equipped to manage these patients effectively and appropriately. As a result, this review highlights the effective management of obese patients undergoing surgery focusing on the preoperative, perioperative and postoperative care of these patients.

Compliance with antibiotic prophylaxis guidelines in caesarean delivery: a retrospective, drug utilization study (indication-prescription type) at an Ecuadorian hospital

BACKGROUND

Preoperative antibiotic prophylaxis is essential for preventing surgical site infection (SSI). The aim of this study was to evaluate compliance with international and local recommendations in caesarean deliveries carried out at the Obstetrics and Gynaecology Service of the Ambato General Hospital, as well as any related health and economic consequences.

METHODS

A retrospective indication-prescription drug utilization study was conducted using data from caesarean deliveries occurred in 2018. A clinical pharmacist assessed guidelines compliance based on the following criteria: administration of antibiotic prophylaxis, antibiotic selection, dose, time of administration and duration. The relationship between the frequency of SSI and other variables, including guideline compliance, was analysed. The cost associated with the antibiotic used was compared with the theoretical cost considering total compliance with recommendations. Descriptive statistics, Odds Ratio and Pearson Chi Square were used for data analysis by IBM SPSS Statistics version 25.

RESULTS

The study included 814 patients with an average age of 30.87 ± 5.50 years old. Among the caesarean sections, 68.67% were emergency interventions; 3.44% lasted longer than four hours and in 0.25% of the deliveries blood loss was greater than 1.5 L. Only 69.90% of patients received preoperative antibiotic prophylaxis; however, 100% received postoperative antibiotic treatment despite disagreement with guideline recommendations (duration: 6.75 ± 1.39 days). The use of antibiotic prophylaxis was more frequent in scheduled than in emergency caesarean sections (OR = 2.79, P = 0.000). Nevertheless, the timing of administration, antibiotic selection and dose were more closely adhered to guideline recommendations. The incidence of surgical site infection was 1.35%, but tended to increase in patients who had not received preoperative antibiotic prophylaxis (OR = 1.33, P = 0.649). Also, a significant relationship was found between SSI and patient age (χ2 = 8.08, P = 0.036). The mean expenditure on antibiotics per patient was 5.7 times greater than that the cost derived from compliance with international recommendations.

CONCLUSIONS

Surgical antibiotic prophylaxis compliance was far below guideline recommendations, especially with respect to implementation and duration. This not only poses a risk to patients but leads to unnecessary expenditure on medicines. Therefore, this justifies the need for educational interventions and the implementation of institutional protocols involving pharmacists.

Antibiotic prophylaxis in breast cancer surgery. A randomized controlled trial

Purpose

To assess the effect of antibiotic prophylaxis on surgical site infection (SSI) rates in women undergoing breast cancer surgery in two tertiary hospitals in Brazil.

Methods

This was a randomized, double-blind, placebo-controlled, parallel-group clinical trial. A total of 124 women without independent risk factors for SSI were randomly assigned to receive either cefazolin (antibiotic group, n = 62) or placebo (control group, n = 62) as preoperative prophylaxis. After surgery, all surgical wounds were examined once a week, for four weeks, according to the Centers for Disease Control and Prevention definitions and classifications for SSI.

Results

Baseline characteristics were homogeneous between the two groups. Only one patient in the antibiotic group developed SSI, which was classified as superficial incisional. The overall SSI rate was low, with no significant difference between groups.

Conclusion

Antibiotic prophylaxis had no significant effect on reducing SSI rates in women without independent risk factors for SSI undergoing breast cancer surgery.

Predictive Factors for Surgical Site Infections in Patients Undergoing Surgery for Breast Carcinoma

INTRODUCTION

Operative interventions for breast cancer are generally classified as clean surgeries. Surgical site infections (SSIs), while rare, do occur. This study sought to identify risk factors for SSI, using the National Surgical Quality Improvement Program (NSQIP).

METHODS

NSQIP's participant use data files (PUF) between 2012 and 2015 were examined. Female patients with invasive breast cancer who underwent surgery were identified through CPT and ICD9 codes. Non-SSI and SSI groups were compared and the statistical differences were addressed through propensity score weighting. Multivariate logistic regression testing was used to identify predictors of SSI.

RESULTS

This study examined 30 544 lumpectomies and 23 494 mastectomies. SSI rate was 1126/54 038 patients (2.1%). In the weighted dataset, mastectomy, diabetes, smoking, COPD, ASA class-severe, BMI >35 kg/m², and length of stay (LOS) >1 day were associated with an increased odds ratio (OR) of SSI. The OR for SSI was highest after mastectomy with reconstruction (OR 2.626, P < .001; 95% CI 2.073-3.325). Postoperative variables associated with an increased OR of SSIs included systemic infection, unplanned reoperation wound dehiscence, and renal failure.

CONCLUSION

Mastectomy, diabetes, smoking, COPD, ASA class-severe, BMI >35 kg/m², length of stay (LOS) >1 day are associated with an increased OR for SSIs following breast surgery.

The relationship between post-surgery infection and breast cancer recurrence

Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.

Impact of contemporary therapy- concepts on surgical morbidity in breast cancer patients: A retrospective single center analysis of 829 patients

INTRODUCTION

Morbidity after breast cancer surgery remains low with revision surgery below 5%. This retrospective monocentric study investigates whether new methods like neoadjuvant chemotherapy (nCT), oncoplastic surgery (OPS) or intraoperative radiotherapy (IORT) affect overall morbidity. In addition, we sought to determine a possible effect of morbidity on oncologic outcome.

METHODS

Clinical Data from all breast cancer cases, operated at the OnkoZert"- certified Breast Health Center of the "Sisters of Charity Hospital" in Linz between 2011 and 2014, were evaluated. Age (≤/>70), nCT, IORT, surgical technique and histological subtypes were analyzed concerning their impact on morbidity. Overall survival (OS) and disease-free survival (DFS) were assessed by Kaplan-Meier estimates.

RESULTS

829 patients were included, 24% were older than 70y, 19% underwent oncoplasty, 5.5% immediate reconstruction, 17% of the invasive cancers were treated with nCT and 4.1% received IORT. One or more complications occurred in 83 patients (10%), while 62 patients (7.5%) underwent revision surgery. Univariate analysis showed that mastectomy and age >70 doubled the risk of surgical morbidity. Multivariate regression analysis identified age >70 as the only independent prognostic parameter for the occurrence of morbidity (OR: 2.42, 95% CI: 1.41-4.1, p = 0,00134). Morbidity was not associated with worse oncologic outcome in terms of OS or DFS.

SUMMARY

In our patient collective, modern techniques such as nCT, OPS or IORT did not influence surgical morbidity rates. Those were only increased by patient's age. Additionally, surgical morbidity did not show any significant impact on OS and DFS.

Perioperative care of the obese patient

Background

Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.

Methods

A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.

Results and conclusion

Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.

Peri-Operative Antibiotic Prophylaxis Does Not Reduce Surgical Site Infection in Breast Cancer

Background: The reported rate of surgical site infection (SSI) in breast surgery is often higher than expected. Using antibiotic prophylaxis to reduce SSI is debatable because of the risk of developing bacteria resistance and the cost burden. In this study, we evaluated the effectiveness of antibiotic prophylaxis in breast surgery and the factors predisposing patients to SSI. Methods: A retrospective-prospective (ambispective) study was conducted in the Department of Breast Surgery, Qilu Hospital, P.R. China. The retrospective antibiotic-using group was composed of patients found to have breast cancer between January 2008 and October 2010. The prospective non-antibiotic-using group was composed of patients identified between November 2010 and November 2013. Pre-operative, peri-operative, and post-operative clinical data were analyzed. Results: The SSI rate of the non-prophylaxis and prophylaxis groups was 1.1% (11/1,022) and 1.2% (12/1,034), respectively. Neoadjuvant chemotherapy was related to SSI in the non-prophylaxis group (p = 0.026). Staphylococcus aureus was the predominant microorganism responsible for SSI, without obvious resistance to a widely used first-generation cephalosporin. Conclusions: Peri-operative antibiotic prophylaxis is of no significant value in preventing SSI in breast cancer surgery. Our results indicated that neoadjuvant chemotherapy might be a risk factor doe SSI, but further research is needed because of the sample size disparity between infected and uninfected groups.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

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.

Identifying the superior antibiotic prophylaxis strategy for breast surgery: A network meta-analysis

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.

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.

Prevention of Surgical Site Infections: A Systematic Review of Cost Analyses in the Use of Prophylactic Antibiotics

Introduction: The preoperative phase is an important period in which to prevent surgical site infections (SSIs). Prophylactic antibiotic use helps to reduce SSI rates, leading to reductions in hospitalization time and cost. In clinical practice, besides effectiveness and safety, the selection of prophylactic antibiotic agents should also consider the evidence with regard to costs and microbiological results. This review assessed the current research related to the use of antibiotics for SSI prophylaxis from an economic perspective and the underlying epidemiology of microbiological findings.

Methods: A literature search was carried out through PubMed and Embase databases from 1 January 2006 to 31 August 2017. The relevant studies which reported the use of prophylactic antibiotics, SSI rates, and costs were included for analysis. The causing pathogens for SSIs were categorized by sites of the surgery. The quality of reporting on each included study was assessed with the “Consensus on Health Economic Criteria” (CHEC).

Results: We identified 20 eligible full-text studies that met our inclusion criteria, which were subsequently assessed, studies had in a reporting quality scored on the CHEC list averaging 13.03 (8–18.5). Of the included studies, 14 were trial-based studies, and the others were model-based studies. The SSI rates ranged from 0 to 71.1% with costs amounting to US$480-22,130. Twenty-four bacteria were identified as causative agents of SSIs. Gram negatives were the dominant causes of SSIs especially in general surgery, neurosurgery, cardiothoracic surgery, and obstetric cesarean sections.

Conclusions: Varying results were reported in the studies reviewed. Yet, information from both trial-based and model-based costing studies could be considered in the clinical implementation of proper and efficient use of prophylactic antibiotics to prevent SSIs and antimicrobial resistance.

A randomized controlled trial on the effect of a silver carboxymethylcellulose dressing on surgical site infections after breast cancer surgery

BACKGROUND

The incidence of surgical site infections (SSIs) after breast cancer surgery is relatively high; ranging from 3 to 19%. The role of wound dressings in the prevention of SSI after breast cancer surgery is unclear. This study compares a silver carboxymethylcellulose dressing (AQUACEL Ag Surgical (Aquacel) with standard wound dressing in SSI rate after breast cancer surgery.

PATIENTS AND METHODS

A single-centre randomized controlled trial among women ≥18 years, diagnosed with breast cancer, undergoing breast conserving or ablative surgery, was conducted in a combined in and outpatient setting. The intervention was the use of Aquacel, compared with standard gauze dressing. Primary outcome measure was SSI following CDC criteria.

RESULTS

A total of 230 patients were analysed: 106 in the Aquacel group and 124 controls. Seven patients (6.6%) developed SSI in the Aquacel group and 16 patients (12.9%) in the control group (RR 0.51 [95% Confidence Interval (CI): 0.22-1.20]; p = 0.112; adjusted OR 0.49 [0.19-1.25] p = 0.135)). Unplanned exploratory subgroup analysis of breast conserving surgery patients showed that SSI rate was 1/56 (1.8%) in the Aquacel group vs. 7/65 (10.8%) in controls; adjusted OR 0.15 [0.02-1.31] p = 0.087. The Aquacel group showed better patient satisfaction (median 8 vs. 7 on a Numerical Rating Scale, p = 0.006), fewer dressing changes within 48 hours(adjusted OR 0.12 [0.05-0.27] p<0.001), fewer re-operations (0% vs. 3.2%, p = 0.062), and lower mean wound-related treatment costs, both in a high (€265.42 (SD = 908) vs. €470.65 (SD = 1223) [p<0.001]) and low (€59.12 (SD = 129) vs. €67.55 (SD = 172) [p<0.001]) attributable costs of SSI model.

CONCLUSION

In this randomized controlled trial in women undergoing surgery for breast cancer, the use of AQUACEL Ag Surgical wound dressing did not significantly reduce the occurrence of SSIs compared to standard gauze dressing. The use of Aquacel resulted in significantly improved patient satisfaction, reduced dressing changes and reduced wound-related costs.

TRIAL REGISTRATION

www.trialregister.nl: NTR5840.

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.

Dressing Wear Time after Breast Reconstruction: A Randomized Clinical Trial

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

ClinicalTrials.gov NCT01148823

Cost-Effectiveness Analysis of the Use of a Prophylactic Antibiotic for Patients Undergoing Lower Limb Amputation due to Diabetes or Vascular Illness in Colombia

BACKGROUND

The use of a prophylactic antibiotic in an amputation surgery is a key element for the successful recovery of the patient. We aim to determine, from the perspective of the Colombian health system, the cost-effectiveness of administering a prophylactic antibiotic among patients undergoing lower limb amputation due to diabetes or vascular illness in Colombia.

METHODS

A decision tree was constructed to compare the use and nonuse of a prophylactic antibiotic. The probabilities of transition were obtained from studies identified from a systematic review of the clinical literature. The chosen health outcome was reduction in mortality due to prevention of infection. The costs were measured by expert consensus using the standard case methodology, and the resource valuation was carried out using national-level pricing manuals. Deterministic sensitivity, scenarios, and probabilistic analyses were conducted.

RESULTS

In the base case, the use of a prophylactic antibiotic compared with nonuse was a dominant strategy. This result was consistent when considering different types of medications and when modifying most of the variables in the model. The use of a prophylactic antibiotic ceases to be dominant when the probability of infection is greater than 48%.

CONCLUSIONS

The administration of a prophylactic antibiotic was a dominant strategy, which is a conclusion that holds in most cases examined; therefore, it is unlikely that the uncertainty around the estimation of costs and benefits change the results. We recommend creating policies oriented toward promoting the use of a prophylactic antibiotic during amputation surgery in Colombia.

Are Breast Surgical Operations Clean or Clean Contaminated?

The breast surgeries are classically taught as clean surgical procedures. The infection rates following breast surgery ranges from 3 to 15 %, which is much higher than infection rates after clean surgery (ranging from 1.5 to 3 %). This high infection rate following breast surgery can be explained by opening of the ductal system to outside world through nipple similar to the gastrointestinal and genitourinary system. We conducted a systematic review of infection following breast surgeries. We searched various randomized controlled trials, meta-analysis, and Cochrane Reviews over PubMed and Medline via the Internet. These evidences were found to support the thesis, "Breast surgeries need to be reclassified as clean-contaminated". We recommend the use of prophylactic antibiotics in breast surgery.

Economic Evaluation of Interventions for Prevention of Hospital Acquired Infections: A Systematic Review

Objective

This systematic review sought to assess the costs and benefits of interventions preventing hospital-acquired infections and to evaluate methodological and reporting quality.

Methods

We systematically searched Medline via PubMed and the National Health Service Economic Evaluation Database from 2009 to 2014. We included quasi-experimental and randomized trails published in English or German evaluating the economic impact of interventions preventing the four most frequent hospital-acquired infections (urinary tract infections, surgical wound infections, pneumonia, and primary bloodstream infections). Characteristics and results of the included articles were extracted using a standardized data collection form. Study and reporting quality were evaluated using SIGN and CHEERS checklists. All costs were adjusted to 2013 US$. Savings-to-cost ratios and difference values with interquartile ranges (IQRs) per month were calculated, and the effects of study characteristics on the cost-benefit results were analyzed.

Results

Our search returned 2067 articles, of which 27 met the inclusion criteria. The median savings-to-cost ratio across all studies reporting both costs and savings values was US $7.0 (IQR 4.2–30.9), and the median net global saving was US $13,179 (IQR 5,106–65,850) per month. The studies’ reporting quality was low. Only 14 articles reported more than half of CHEERS items appropriately. Similarly, an assessment of methodological quality found that only four studies (14.8%) were considered high quality.

Conclusions

Prevention programs for hospital acquired infections have very positive cost-benefit ratios. Improved reporting quality in health economics publications is required.

The effects of epidural anesthesia on growth of Escherichia coli at pseudosurgical site: the roles of the lipocalin-2 pathway

BACKGROUND

Neutrophil-derived lipocalin-2 exerts bacteriostatic effects through retardation of iron uptake by the Gram-negative organisms like Escherichia coli. We tested the hypothesis that the expression of lipocalin-2, a bacteriostatic protein, was upregulated by induction of surgical site infection (SSI) with E coli in healthy and diseased rats and that epidural anesthesia modulated its expression.

METHODS

Male Wistar rats were randomized into a healthy or disease group, the latter of which was administered lipopolysaccharide. Both groups were further divided into 3 subgroups, the control, saline, and lidocaine groups: group healthy control (n = 10), healthy saline (n = 10), and healthy lidocaine (n = 10) versus group disease control (n = 15), disease saline (n = 18), and disease lidocaine (n = 19), respectively. While saline was epidurally administered to the control and saline groups, lidocaine was administered to the lidocaine groups. Except for the control groups, E coli was injected to the pseudosurgical site to mimic SSI after abdominal surgery. Plasma concentrations of inflammatory cytokine and lipocalin-2 were measured. At 72 hours, the surgical site tissues were obtained to evaluate mRNA expression of lipocalin-2 and E coli DNA expression.

RESULTS

All disease subgroups showed markedly increased plasma inflammatory cytokines versus the healthy subgroups. Among the disease subgroups, plasma concentrations of lipocalin-2 and tissue mRNA expression of lipocalin-2 were significantly increased in group disease lidocaine versus the others. Concurrently, E coli DNA expression in the tissue specimens was also significantly lower in group disease lidocaine as compared with group disease saline.

CONCLUSIONS

Epidural anesthesia was associated with an increase in the expression lipocalin-2 and a decrease in the expression of E coli DNA at pseudosurgical sites in sick but not healthy rats. These observations suggest a potential mechanism by which epidural anesthesia could reduce the risk of SSI.

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.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

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.

Surgeon behavior and knowledge on hand scrub and skin antisepsis in the operating room

BACKGROUND

Surgical site infections adversely affect patients' well-being. In this study, hand-washing details and adherence to surgical site antisepsis applications among surgical staff were observed and recorded. Then, a questionnaire was given to test surgeons' theoretical knowledge on operating room principles.

METHODS

Staffs from 5 surgical units were selected (surgeons and nurses from general surgery, urology, plastic surgery, thoracic surgery, and gynecology and obstetrics) and observed. They were questioned on the choice and properties of antiseptics, proper duration of hand washing and use of brushes, and essentials of patient skin antisepsis.

RESULTS

A total of 107 observations (53 residents, 27 nurses, 6 attending staff, and 21 academic staff) were done. Overall mean (± standard deviation) hand-washing time was 69.1 (49.8) seconds (range: 43.8-98; p: 0.001). Overall, 79 (73.8%) never used a brush, 18 (16.8%) used the brush for the nails only, and 10 (9.4) used the brush for hands and arms as well as the nails. Mean (± standard deviation) time from the application of skin antiseptic to surgical incision time was 6.7 (3.5) minutes (p: 0.088). According to the questionnaire, surgeons believed that proper hand-washing time should be 4.2 ± 2.8 minutes (p = 0.13). Brush usage was questioned and 50 (70.4%) favored brush usage whereas 21 (29.6%) were against it. The question for mechanism of action of povidone iodine is answered as 'bactericidal' by only 69%.

CONCLUSION

The study shows that both adherence to local hand-hygiene protocols and surgical staffs' basic knowledge about surgical antisepsis are low.

National practice in antibiotic prophylaxis in breast cancer surgery

Background

Although breast cancer surgery is regarded as a “clean” surgery, surgical site infection (SSI) rates are higher than expected. There is no consensus regarding the use of antibiotic prophylaxis in elective breast surgery. The nationwide survey was conducted to determine the trend of antibiotic prophylaxis in breast cancer among Turkish surgeons.

Methods

The survey was sent to surgeons who are member of Turkish Surgical Association (TSA) via e-mail from TSA web address. A 15 item web-based survey consisted of surgeon demographics and the use of prophylactic antibiotic in patients with risk factors related to SSI.

Results

The number of completed questionnaires was 245. The most common antibiotic used was first generation of cephalosporins. A majority of respondents indicated that prophylaxis was preferred in patients with high risk of SSI including preoperative chemotherapy or radiotherapy, older age, diabetes mellitus, immunodeficiency, immediate reconstruction (P < 0.05). However, the use of drain did not significantly influence antibiotic prophylaxis (P = 0.091).

Conclusions

The use of prophylactic antibiotic was strongly dependent on the presence of some risk factors; however, the variation in current practice regarding antibiotic prophylaxis demonstrated a lack of its effect on preventing SSI after breast cancer surgery.

Efficacy of prophylactic antibiotic administration for breast cancer surgery in overweight or obese patients: research highlight

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.