Antibiotic Stewardship in Breast Reconstruction
Franca Kraenzlin, Kristen Broderick.
Johns Hopkins, Baltimore, MD, USA.
The Centers for Disease Control and the Surgical Care Improvement Project recommends that clean surgical cases receive a maximum of 24 hours of perioperative antibiotics. While breast surgery is considered a clean case, implant based breast reconstruction has decidedly higher rates of infection than the typical 1% to 2% rate of surgical site infections. Surgical site infections for implant based reconstructive cases vary widely, but studies have quoted an up to 31% infection rate. As a result, plastic surgeons almost universally provide prolonged antibiotic regimens following expander based reconstruction. In one survey based study capturing 650 respondents, 46% of surgeons preferred concomitant discontinuation of antibiotics with drains, whereas 52% preferred cessation of antibiotics on a specific postoperative day. While retrospective studies looking at antibiotic duration and infection rate have been mixed, a first in kind prospective study completed in 2016 found no benefit for prolonged antibiotics. In this study, we sought to analyze how the use of prolonged antibiotics affect complication severity.
A retrospective review of all post mastectomy patients receiving tissue expanders (TE) was completed for 2017. Per Department protocol, patients are discharged with a minimum of 14 days of post-operative antibiotics. However, overall antibiotic length is per attending preference, with subsequent prescriptions written for patients in the outpatient setting. Infection was defined as concerning clinical exam prompting oral antibiotic prescriptions or intravenous antibiotics, IR seroma drainage with positive cultures, or a return to the operating room (RTOR) for suspected infection.
A total of 178 individuals underwent mastectomy and TE reconstruction in 2017. Average mastectomy weight was 605.3 grams, 50.0% underwent a prepectoral procedure, and 44.9% received nipple-sparing mastectomies. 17.4% of individuals suffered from an infection, with 10.1% requiring a RTOR for explantation or washout. Average post-operative antibiotic length was 17.9 days, while infections were diagnosed on average at day 40.6. Individuals with suspected infections received an average of 37.2 days of antibiotics. Antibiotic duration longer than 14 days compared to duration less than 14 days did not decrease the risk of infection (16.1% vs. 18.1%, p-value = 0.74, respectively) or explantation (6.5% vs 12.1%, p-value = 0.24, respectively).
Infection rates or explantation rates do not decrease with longer perioperative antibiotics. Additionally, with infections occurring on average roughly 5.8 weeks following implant placement, antibiotic administration for longer than the CDC recommendation for 24 hours perioperatively, may be fruitless for patients. The lack of antibiotic stewardship may be an important contributor to the morbidity that patients face. Further prospective studies limiting perioperative antibiotics should be completed to further elucidate this problem.
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