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Do Postoperative Prophylactic Antibiotics Reduce Highly Virulent Infections? An Analysis Of 660 Tissue Expander Breast Reconstructions
Kaitlin Monroig, BA1, Kanad Ghosh, BA1, Jocellie Marquez, MD, MBA2, Austin Ferrier, BS1, Christopher Medrano, BA1, William Marmor, BS1, Phoebe McAuliffe, BA1, Kailash Kapadia, MD1, Hunter Rogoff, BS1, Tara Huston, MD, FACS3, Jason Ganz, MD3, Sami Khan, MD3, Duc Bui, MD3.
1Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA, 2Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, 3Division of Plastic and Reconstructive Surgery, Stony Brook University Hospital, Stony Brook, NY, USA.

Purpose:
Many surgeons are reluctant to discontinue prophylactic antibiotics after 24 hours in tissue expander breast reconstruction (TEBR) due to increased risk of surgical site infection (SSI). There is currently no consensus regarding antibiotic prophylaxis duration in TEBR. In addition, there remains a lack of research investigating microorganisms involved in SSI across various perioperative antibiotic protocols. The purpose of this study was to examine how two different prophylactic antibiotic regimens impacted the bacterial profiles of SSI and rate of implant loss after TEBR. 
Methods:
A single institution retrospective review was performed of immediate TEBRs between 2001-2018. Demographics, chemotherapy/radiation, prophylactic antibiotic regimen and SSI cultures were analyzed. SSIs requiring hospitalization before stage 2 were included. Outpatient managed SSIs were excluded. Highly virulent organisms were defined as ESKAPE pathogens (Enterococcus faecium, Staphylococcus Aureus, Klebsiella Pneumoniae, Acinetobacter baumannii, Pseudomonas Aeruginosa, Enterobacter species) based on literature. Implant loss was defined as removal of TE without immediate replacement.
Results:
Of 660 TEBRs, 85 (12.9%) developed an SSI prior to stage 2. Fifty-six (65.9%) previously received <24 hours perioperative prophylactic IV antibiotics and oral antibiotics after discharge (Group 1) and 29 (34.1%) were given <24 hours prophylactic IV antibiotics only (Group 2). There was no significant difference in demographics (i.e. BMI, age, smoking status, preoperative chemotherapy/radiation) or inpatient treatment of the SSI (Oral/IV antibiotics) between the two groups. In Group 1, 64% (n=36) developed culture positive SSIs, compared to 83% (n=24) in Group 2. Staphylococcus Aureus was the most common bacteria in both groups.
Group 2 demonstrated a significantly increased incidence of gram-positive organisms (46.4% vs 72.4%, p=0.022) and Staphylococcus Aureus (21.4% vs 55.2%, p=0.002). However, there was no significant difference in overall highly virulent (p=0.168), gram-negative (p=0.416), or total isolated organisms (p=0.192) between groups. Interestingly, Group 1 demonstrated an increase in Pseudomonas Aeruginosa SSIs, (14.3% vs 3.4%, p=0.124) but this finding did not reach significance. Implant loss between Groups 1 and 2 (62.5% vs. 62.1%, p=0.969) respectively, was nearly identical.
Conclusion:
Our study demonstrates that despite differences in bacterial profiles between the two antibiotic protocols, prolonged postoperative antibiotic use did not provide additional protection against overall highly virulent infections. In addition, the implant loss rate between the two groups was similar. Antibiotic stewardship guidelines against the overuse of prolonged prophylactic regimens should be considered. Further analysis regarding timing of SSIs and antibiotic treatment is warranted.


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