DOI: 10.1097/PRS.0000000000002738
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PMID: 27879579
Issn Print: 0032-1052
Publication Date: 2016/12/01
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Excerpt
The breast is not a sterile environment but rather contains a diverse community of bacteria, which may have regional variation. In some patients, this environment supports Staphylococcus, Pseudomonas, and other known pathogens in breast implant–related infections.1 The relative ischemia of breast skin after mastectomy combined with introduction of a foreign device in an area of the body that harbors bacteria produces a perfect storm that sets the stage for bacterial proliferation or invasion. So how can we as surgeons minimize the risk of infection?
Several protocols have been suggested to decrease bacterial contamination in both cosmetic and reconstructive breast surgery.2,3 Commonalities of these protocols include adequate skin preparation, intravenous antibiotics before the start of surgery, breast pocket irrigation with a triple-antibiotic solution, one surgeon handling the implant with minimal or no touching of the skin, and good skin closure. In reconstruction, the viability of the mastectomy skin flap is of paramount importance. Additional consideration is given to oral antibiotic administration until the drains are removed.
Clinical studies from the breast literature suggest that drain colonization is common following mastectomy and may have a correlation with clinical infection. One study reported rates of drain colonization in breast cancer patients who had mastectomy alone without postoperative antibiotics at 33 percent on postoperative day 7 and 81 percent at postoperative day 14.4 This correlated with an infection rate of 17 percent. Over 80 percent of the infections were caused by the bacteria cultured from the drains. In another study of mastectomy patients without reconstruction on antibiotics for 24 hours, cultures from the drain bulb at 1 week were positive in 66 percent of patients receiving routine care.5 Nineteen percent of drain tubes had more than 50 colony-forming units and the rate of surgical site infection was 6 percent. What remains unknown is whether prolonged oral antibiotic administration can reduce rates of drain colonization and, most importantly, clinical infection following mastectomy and immediate prosthetic breast reconstruction.
The authors attempt to answer this important question with a meta-analysis. Their article examines the current data on administration of antibiotics and postoperative infection and implant loss in patients undergoing immediate prosthetic breast reconstruction. Five heterogeneous studies with somewhat conflicting outcomes met inclusion criteria. The authors table and pool the results. They found two studies showing a clear benefit to prolonged antibiotics. These studies show that patients who received less than 24 hours of antibiotics had a higher relative risk of infection and explantation. Two other studies show no difference in risk of infection or implant loss between the groups. A final study shows similar risks of infection but a higher risk of explantation with prolonged antibiotics. When the data are pooled, prolonged antibiotics did not have a statistically significant effect on decreasing the rate of infection or implant loss.
