Perioperative antibiotic prophylaxis in implant breast reconstruction
Article information
Abstract
Implant infection is the most common and serious complication in implant-based breast reconstruction. To prevent infection, many surgeons have adopted a perioperative antibiotic prophylaxis regimen for managing patients. However, there has been considerable debate regarding the duration of antibiotic prophylaxis. After reading this article, plastic surgeons should manage their patients with an understanding of the evidence supporting perioperative antibiotic prophylaxis.
INTRODUCTION
Implant infection is a common and serious complication in implant-based breast reconstruction. Infection rates have been reported at approximately 2% among patients undergoing this type of reconstruction. Infections can range from mild cellulitis to severe abscesses that necessitate implant removal. Once an infection occurs, the social and economic costs are significant, and the patient’s return to normal life is delayed. For these reasons, surgeons strive to prevent infections by administering antibiotics to reduce infection rates. The antibiotic regimen is categorized based on the timing of administration. “Preoperative” refers to antibiotic therapy administered within 24 hours before surgery. “Intraoperative” refers to antibiotics given in the operating room and discontinued immediately afterward. “Perioperative” encompasses antibiotic therapy from the start of surgery until departure from the recovery room. “Postoperative” describes antibiotics administered after leaving the recovery room and continuing until a specified postoperative period. Several studies have indicated that preoperative prophylactic antibiotics before breast reconstruction surgery aid in controlling infections [1-4]. However, there is ongoing debate regarding the optimal duration of antibiotic use. In this article, we will review the use of antibiotics in implant-based breast reconstruction.
PERIOPERATIVE ANTIBIOTICS
Perioperative antibiotic prophylaxis remains a contentious topic in implant-based reconstruction. Numerous studies have attempted to address this issue. In 2012, Clayton et al. [5] conducted a retrospective study to compare infection rates in patients before and after the implementation of the Surgical Care Improvement Project (SCIP) protocol. The SCIP protocol limited the use of postoperative antibiotics to no more than 24 hours. Prior to adopting this protocol, antibiotics were administered until the surgical drains were removed. The study revealed infection rates of 18.1% before SCIP implementation and 34.3% after, indicating a significant increase. Furthermore, the odds ratio for infection rates post-SCIP compared to pre-SCIP was 4.74, also showing a significant difference. The findings led to the conclusion that withholding postoperative antibiotics could be associated with an increased risk of infection.
In 2013, Phillips et al. [6] conducted a systematic review to explore the relationship between antibiotic use and infection rates. They analyzed a total of 81 articles, categorizing patients based on the duration of antibiotic administration. The findings revealed that the group receiving no antibiotics had an infection rate of 14.44%, the group treated for up to 24 hours had a rate of 5.76%, and the group treated for over 24 hours had a rate of 5.78%. In a separate study in 2013, Avashia et al. [7] compared the infection rates between postoperative patients who received antibiotics for less than 24 hours and those who received them for more than 48 hours. The study periods for the >48 hours regimen spanned from June 2017 to September 2009 and from November 2009 to August 2010, while the <24 hours regimen was applied from October 2009 to November 2009. The infection rate was significantly higher in the <24 hours group at 31.6%, compared to 6.7% in the >48 hours group.
In 2016, Phillips et al. [8] conducted a prospective randomized controlled trial to assess the necessity of prophylactic postoperative antibiotics. They divided the patients into two groups: one received antibiotics for 24 hours (n=62), and the other continued antibiotics until drain removal (n =50). The incidence of infection was 19.35% in the 24-hour group and 22.0% in the drain removal group, with no significant difference between the two. Consequently, they concluded that limiting postoperative antibiotics to 24 hours did not lead to an increase in infectious complications.
In 2016, Phillips and Halvorson [9] conducted a review to compare various perioperative prophylactic antibiotic regimens and their impact on infectious outcomes in prosthetic breast reconstruction. They analyzed five individual studies and five systematic reviews. Their conclusion was that a minimum of 24 hours of antibiotic prophylaxis is not inferior to prolonged regimens extending beyond 24 hours. Consequently, they recommended limiting the duration of postoperative antibiotic use to 24 hours. However, they noted limitations, including the lack of demonstrated superiority of the 24-hour prophylaxis and unresolved questions regarding the optimal duration of antibiotics and the standardization of outcomes.
In 2016, Wang et al. [10] reviewed five studies, including a randomized controlled trial involving 927 individual studies. They compared two groups: one receiving prolonged prophylactic antibiotics and the other receiving no prolonged prophylactic antibiotics. They observed that the incidence of surgical site infections was 14% in the prolonged antibiotics group and 19% in the group treated for less than 24 hours. The relative risk was 1.43, with no significant difference noted. Additionally, the incidence of implant loss was 8% in the prolonged antibiotics group and 10% in the less than 24 hours group, with a relative risk of 1.66, also without a significant difference.
In 2018, Ranganathan et al. [11] analyzed a large dataset of patients who underwent implant-based breast reconstruction. A total of 7,443 patients were categorized based on the duration of postoperative antibiotic prophylaxis: none, 1–5 days, 6–10 days, and >10 days. The researchers utilized multivariate analysis to examine the rates of wound infection. They reported an odds ratio of 0.89 for patients who did not receive antibiotic prophylaxis. Additionally, the likelihood of developing an infection was found to be similar across the different durations of prophylaxis (1–5 days: 0.79, 6–10 days: 0.88, >10 days: 1.01). The study concluded that postoperative antibiotic prophylaxis was not associated with a reduced risk of infection.
In 2023, Sisco et al. [12] investigated the effectiveness of oral antibiotics in immediate implant-based breast reconstruction. They implemented an extended antibiotic prophylaxis regimen, administering oral antibiotics until the removal of drains before October 2016. Their study compared the clinical outcomes of extended antibiotic prophylaxis with no prophylaxis. They found no improvement in clinical outcomes with extended antibiotic prophylaxis. Additionally, they observed that extended use of oral antibiotics led to microbiological changes in infections, complicating treatment. In 2024, Sergesketter et al. [13] examined the efficacy of prophylactic postoperative antibiotics in prosthetic breast reconstruction through a propensity score-matched analysis. Their findings indicated that infection rates were equivalent when comparing 24 hours of perioperative antibiotics with longer durations (Table 1).
Impact of prophylaxis using systemic antibiotics on implant-based breast reconstruction
CONCLUSION
Between 2012 and 2016, there were conflicting reports regarding the optimal duration of perioperative antibiotic prophylaxis in implant-based breast reconstruction. Following a randomized controlled study by Phillips et al. [8], it was indicated that less than 24 hours of intravenous antibiotics were sufficient to prevent infection in implant-based breast reconstructions. Subsequent studies conducted after 2016 also demonstrated the non-inferiority of infection rates with less than 24 hours of perioperative antibiotic prophylaxis. Moreover, prolonged antibiotic prophylaxis can lead to microbiological differences in infections, making them more difficult to treat. However, no studies have demonstrated the superiority of less than 24 hours of antibiotic prophylaxis. In the future, a large-scale prospective randomized controlled study will be necessary to prove that extended antibiotic prophylaxis does not benefit patient management.
Notes
Woo Yeon Han is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.