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Antibiotic Selection in the Treatment of Infectious Complications of Immediate Implant Based Breast Reconstruction
Katie Weichman, MD, Steve Levine, MD, Stelios Wilson, BS, Mihye Choi, MD, Nolan Karp, MD.
New York University, New York, NY, USA.
Purpose: Infection requiring explantation remains the most dreaded and devastating complication associated with implant-based breast reconstruction. There are many treatment algorithms to prevent reconstructive failure in the face of infection utilizing both oral and intravenous antibiotics. In the absence of patient specific culture data, antibiotic selection is generally directed towards broad-spectrum coverage based on historical data. We hypothesize that reviewing our institutions microbiology data obtained from explanted implant-based breast reconstructions would provide a rational basis for antibiotic selection in the future.
Methods: A retrospective review of 902 consecutive immediate implant based breast reconstructions at a single institution from November 2007 to May 2011 was conducted. Implants requiring explantation and interventional radiology drainage were identified. Patient demographics, implant characteristics, use of ADM, presence of skin necrosis, microbiological data, and outcomes were reviewed for analysis.
Results: Fifty-four (5.98%) implants requiring explantation and two (0.5%) reconstructions requiring radiologic guided drainage were identified. A total of forty-three implants were included for analysis because thirteen implants lacked culture data. Eight permanent round smooth silicone implants and thirty-five round textured tissue expanders were explanted with average size 637mL and 430mL respectively. Twenty-six implants were explanted due to infection, three due to exposure from skin necrosis, eleven due to combination of flap necrosis and infection, and one implant was removed for cancer invasion. Reconstruction was salvaged in twenty-eight breasts (56.0%); thirteen with implant reconstruction; five with pedicled latissimus dorsi flap and ten breasts went on to microvascular free flap reconstruction. Thirty explants had microbiology data available. The most common organism isolated was staphylococcus epiderminis (10), followed by serratia marcescens (5), staphylococcus aureus (5), pseudomonas aeruginosa (4), enterococcus (3), enterobactr (2), ecoli (2) and MRSA (1). 56% of reconstructions received pre-culture Vancomycin. 40% of organisms were resistant to Cefazolin, however, 86% were sensitive to Gentamycin, 80% sensitive to Levaquin and 63% to Ciprofloxacin.
Conclusions: Infections associated with implant-based breast reconstructions continues to threaten explantation and reconstructive failure. Based on our microbiologic data, initial cellulitis amenable to oral antibiotics should be treated with oral fluoroquinolones as a first line treatment. If this regiment fails, intravenous Gentamycin or Imipenem and Vancomycin should be initiated. Obviously, clinical judgment regarding specific patient risk factors and compliance plays a role in decision-making, but this data provides an evidence-based rational for first line antibiotic selection
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