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A Critical Analysis Of Surgical Site Infection After Immediate Tissue Expander Reconstruction Of The Breast: Are The Current Antibiotic Guidelines Effective?
Meghan C. McCullough, BA, Carrie Chu, MD, Claire Duggal, MD, Albert Losken, MD, Grant W. Carlson, MD.
Emory University School of Medicine, Atlanta, GA, USA.
Purpose: The Surgical Care Improvement Project (SCIP) has established guidelines for antibiotic prophylaxis to reduce surgical site infections (SSI). These include administering appropriate antibiotics within 60 minutes of incision and discontinuing them within 24 hours of surgery. These guidelines were not developed according to surgery type or specialty. A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics after hospital discharge for breast reconstruction. There is no clinical evidence that this practice reduces SSI after immediate tissue expander breast reconstruction.
Methods: A prospectively-maintained institutional breast reconstruction database from 2005 and 2011 was queried to identify patients undergoing immediate tissue expander reconstruction of the breast. Prophylactic antibiotics were administered in all cases. Cefazolin was routinely used but clindamycin or vancomycin was used in penicillin-allergic patients. SSI was defined by standardized criteria from the Centers for Disease Control. The bacteriology of the infection, perioperative measures including prophylactic antibiotic use and skin preparation, timing of infection, and antibiotic sensitivities were analyzed.
Results: 568 cases of immediate tissue expander breast reconstruction were performed in 386 patients. SSI was diagnosed in 50 cases (8.8%), a median of 29 days after surgery. Two hundred patients were given oral antibiotics at discharge, 179 did not receive antibiotics, and in 7 patients antibiotic status was unknown. SSI developed in 12% given oral antibiotics and in 13.4% of those not receiving antibiotics (p=0.72). Wound culture data was obtained in 34 SSIs. Twenty-nine had positive cultures including 5 (14.7%) with multiple organisms. Antibiotic sensitivities relative to the administered prophylactic antibiotic were performed in 27 of the wound cultures (Table). The most common offending organism was S aureus. Of the 6 cases which were methicillin-resistant, four patients received prophylactic cephalexin at initial discharge. All cases required reoperation. Of the 12 cases which were methicillin-sensitive, eight received no prophylactic antibiotics. In one case, medical salvage of implant was successfully achieved.
|S. Aureus||11||9 (81.8)||0||2 (18.2)||0|
|MRSA*||6||0||5 (83.3)||1 (16.6)||0|
|Coagulase Negative Staphylococcus||3||3 (100)||0||0||0|
|Alpha Hemolytic Streptococcus||1||0||0||0||1 (100)|
|S. Lugudensis||1||1 (100)||0||0||0|
|Entercoccus||2||1 (50)||1 (50)||0||0|
|M. Fortuitum||3||0||0||2 (66.6)||1 (33.3)|
|Serratia||3||1 (33.3)||2 (66.6)||0||0|
|Pseudomonas||2||1 (50)||1 (50)||0||0|
|Other||3||2 (66.6)||0||0||1 (33.3)|
|Total||36||18 (50)||10 (27.8)||5 (13.9)||3 (8.3)|
Conclusions: Administration of extended prophylactic antibiotics does not reduce overall risk of surgical site infection after implant-based breast reconstruction, but influences antibiotic resistance patterns when infections occur. The benefit and/or risk associated with this common practice deserves further study.
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