Efficacy of short-term antibiotic prophylaxis in immediate two-stage breast reconstruction after mastectomy: A retrospective monocentric study

Impact of post-operative infection on revision procedures in breast reconstruction: A marketscan database analysis

BACKGROUND

Esthetic complications, such as capsular contracture and soft-tissue contour defects, hinder the desired outcomes of breast reconstruction. As subclinical infection is a prevailing theory behind capsular contracture, we investigated the effects of post-operative infections on these issues and revision procedures.

METHODS

We conducted a retrospective database study (2007-2021) on breast reconstruction patients from the MarketScan® Databases. Esthetic complications were defined by their associated revision procedures and queried via CPT codes. Severe capsular contracture (Grade 3-4) was defined as requiring capsulotomy or capsulectomy with implant removal or replacement. Moderate and severe soft-tissue defects were determined by the need for fat grafting or breast revision, respectively. Generalized linear models were used, adjusting for comorbidities and surgical factors (p < 0.05).

RESULTS

We analyzed the data on 62,510 eligible patients. Post-operative infections increased the odds of capsulotomy (OR 1.59, p < 0.001) and capsulectomy (OR 2.30, p < 0.001). They also raised the odds of breast revision for severe soft-tissue defects (OR 1.21, p < 0.001). There was no significant association between infections and fat grafting for moderate defects. Patients who had post-operative infections were also more likely to experience another infection after fat grafting (OR 3.39, p = 0.0018). In two-stage reconstruction, infection after tissue expander placement was associated with greater odds of infection after implant placement.

CONCLUSION

Post-operative infections increase the likelihood of developing severe soft-tissue defects and capsular contracture requiring surgical revision. Our data reinforce the role of infections in the pathophysiology of capsular contracture. Additionally, infections elevate the risk of subsequent infections after fat grafting for moderate defects, further increasing patient morbidity.

Effectiveness of extended antibiotic prophylaxis in implant-based breast reconstruction surgery: A meta-analysis

INTRODUCTION

Considerable research has been carried out on the postoperative benefits of extended antibiotic prophylaxis (EAP) in different surgical contexts, generating various results regarding its effectiveness. Some studies indicate positive outcomes, whereas others indicate no significant advantages. Our approach involves conducting a comprehensive systematic review and meta-analysis to provide a more nuanced understanding of the role of extended antibiotic use because of the lack of a consistent consensus.

METHODS

A thorough search of the Cochrane Library, Embase, and MEDLINE electronic databases was conducted to identify relevant studies. The metafor package in R software was used for meta-analysis. We collected risk ratios (RRs) for surgical site infection (SSI) in the EAP versus non-EAP groups from the included studies to assess the effects of EAP on reducing the risk of SSI. The meta-analysis used a random-effects model, and effect sizes were presented with their corresponding 95% confidence intervals (CIs).

RESULTS

Fourteen studies, involving 12,572 patients who underwent implant-based reconstruction postmastectomy, were included. Pooling the results of the studies that used EAP until drain removal revealed no protective effect of EAP against SSI risk (RR = 0.84; 95% CI: 0.60-1.18). Similarly, our analysis revealed no significant benefit of EAP in studies where EAP was not contingent on drain removal (RR = 0.70; 95% CI: 0.46-1.07).

CONCLUSIONS

EAP administration did not decrease the incidence of SSI in individuals undergoing implant-based breast reconstruction surgery postmastectomy.

Efficacy of Prophylactic Postoperative Antibiotics in Tissue Expander-Based Breast Reconstruction: A Propensity Score-Matched Analysis

BACKGROUND

Conflicting evidence exists regarding the utility of prophylactic postoperative antibiotics in tissue expander (TE)-based breast reconstruction. This study evaluated the risk of surgical-site infection between patients receiving 24 hours of perioperative antibiotics alone versus prolonged postoperative antibiotics within a propensity score-matched cohort.

METHODS

Patients undergoing TE-based breast reconstruction receiving 24 hours of perioperative antibiotics alone were propensity score-matched 1:3 to patients receiving postoperative antibiotics based on demographics, comorbidities, and treatment factors. Incidence of surgical-site infection was compared based on duration of antibiotic prophylaxis.

RESULTS

Of a total of 431 patients undergoing TE-based breast reconstruction, postoperative antibiotics were prescribed in 77.2%. Within this cohort, 348 were included for propensity matching (no antibiotics, 87 patients; antibiotics, 261 patients). After propensity score matching, there was no significant difference in incidence of infection requiring intravenous (no antibiotics, 6.9%; antibiotics, 4.6%; P = 0.35) or oral antibiotics (no antibiotics, 11.5%; antibiotics, 16.1%; P = 0.16). In addition, rates of unplanned reoperation ( P = 0.88) and 30-day readmission ( P = 0.19) were similar. After multivariate adjustment, prescription of postoperative antibiotics was not associated with a reduction in surgical-site infection (OR, 0.5; 95% CI, -0.3 to 1.3; P = 0.23).

CONCLUSIONS

Within a propensity score-matched cohort accounting for patient comorbidities and receipt of adjuvant therapies, prescription of postoperative antibiotics after TE-based breast reconstruction conferred no improvement in rates of TE infection, reoperation, or unplanned health care use. These data underscore the need for multicenter randomized trials on the utility of antibiotic prophylaxis in TE-based breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Tissue Expander-Based Breast Reconstruction at a Major Safety-Net Hospital: Managing the Outsized Risk of Infection

Background

Immediate tissue expander (TE) breast reconstruction is reported to have the highest rate of postoperative infection among reconstructive modalities. The risk of infection is higher among patients treated at safety-net hospitals.

Objectives

The goal of this study was to identify significant contributing factors to the elevated infection risk at our major safety-net institution.

Methods

A retrospective chart review was conducted on all TE-based reconstruction patients with a diagnosis of postoperative infection between 2015 and 2019. Preoperative, perioperative, and postoperative risk factors for infection were determined and compared across patient and procedure demographics.

Results

Two hundred forty-three patients, for a total of 412 breast reconstructions, were included in our study. Significant preoperative selection factors were identified to contribute to the elevated risk of infection, including the following: older age, higher BMI, and diabetes. Significant intraoperative and postoperative contributing factors included greater mastectomy weight, larger TE's and intraoperative fill volume, and longer drain duration. Doxycycline treatment for infected patients resulted in a significantly higher rate of resolution.

Conclusions

Safety-net hospital population patients undergoing TE breast reconstruction are at higher risk for postoperative infection. Personal and procedural risk factors are identified. Balancing the benefits of immediate breast reconstruction with TEs with the elevated risk of postoperative infection remains challenging. Implementation of more stringent eligibility criteria may help mitigate the risk of infection.

Level of Evidence 4