Once Is Not Enough – Postoperative Prophylactic Antibiotics in Prosthetic Breast Reconstruction

Purpose – There has been a recent trend toward limiting perioperative prophylactic antibiotics to a single preoperative dose. This has largely been based on clinical research that was not done in patients undergoing plastic and reconstructive procedures. Our university hospital instituted such a protocol based on pay-for-performance guidelines. An increase in the rate of surgical site infections (SSI) was noted in patients undergoing breast reconstruction and therefore we sought to determine whether the change in antibiotic regimen affected rates of SSI.

Methods – A retrospective cross-sectional study compared a group of patients undergoing breast reconstruction who received pre- and postoperative prophylactic antibiotics (10/2007-10/2008) to a group who received only a single dose of preoperative antibiotic (1/2009-1/2010). Medical records were reviewed for SSI's, defined as infections treated with oral or intravenous antibiotics, or surgery. Type of reconstruction and known risk factors for implant infection were noted. Fisher's exact test and t-tests were used to compare independent risk factors and rates of SSI.

Data – 250 patients were included: 116 in the group receiving postoperative antibiotics and 134 in the group that did not. There were no statistically significant differences in age, BMI, diabetic status, smoking, radiation history, chemotherapy history, or tumor stage between the two groups. The overall rate of SSI increased from 19% to 34.3% (P=0.007). No statistically significant differences were noted in the rates of SSI requiring oral or IV antibiotics, but the rate of infection requiring operation increased from 4.3% to 16.4% (P=0.002). The number of tissue expander SSI's increased from 19.6% to 34.3% (P=0.024). The number of tissue expanders requiring removal increased from 5.4% to 18.2% (P=0.008). There were no statistically significant differences in the rates of SSI for patients undergoing autologous reconstruction.

Summary – Withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of SSI, reoperation, and thus reconstructive failure, most likely due to the presence of a large foreign body. This risk is 3-4 times higher than in patients receiving postoperative prophylactic antibiotics.

Conclusion - Patients undergoing prosthetic breast reconstruction should receive postoperative prophylactic antibiotics.