Perioperative antibiotic prophylaxis and wound infection following breast surgery

Platt, Richard; Zucker, J. R.; Zaleznik, Dori F.; Hopkins, Cyrus C.; Dellinger, E. Patchen; Karchmer, A. W.; Bryan, Charles S.; Burke, John F.; Wikler, Matthew A.; Marino, Susan; Holbrook, K. F.; Tosteson, Tor D.

doi:10.1093/jac/31.suppl_b.43

Cited by 71 publications

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“…The strategy of no prophylaxis was always associated with both higher costs and a greater number of deaths and surgical site infections than either of the two alternative prophylactic strategies. In fact, the cost attributed to failure to provide prophylaxis may have been underestimated, since we assumed that the risk reduction was similar to that observed in other clean surgical procedures (18)(19)(20)(21)(22)(23).…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, we assumed a relative risk of 0.4 for a surgical site infection in patients who received antibiotic prophylaxis compared with those who did not, which corresponds to the highest effectiveness of antibiotic prophylaxis within the range of results from completed placebo-controlled studies in clean surgical procedures other than CABG surgery (18)(19)(20)(21)(22)(23). We used data on the incidence of surgical site infections among patients receiving cefazolin from five surveillance programs in university-affiliated hospitals in Boston (17).…”

Section: Clinical Datamentioning

confidence: 99%

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Clinical Consequences and Cost of Limiting Use of Vancomycin for Perioperative Prophylaxis: Example of Coronary Artery Bypass Surgery

Zanetti

Goldie

Platt

2001

Emerg. Infect. Dis.

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Routine use of vancomycin for perioperative prophylaxis is discouraged, principally to minimize microbial resistance to it. However, outcomes and costs of this recommendation have not been assessed. We used decisionanalytic models to compare clinical results and cost-effectiveness of no prophylaxis, cefazolin, and vancomycin, in coronary artery bypass graft surgery. In the base case, vancomycin resulted in 7% fewer surgical site infections and 1% lower all-cause mortality and saved $117 per procedure, compared with cefazolin. Cefazolin, in turn, resulted in substantially fewer infections and deaths and lower costs than no prophylaxis. We conclude that perioperative antibiotic prophylaxis with vancomycin is usually more effective and less expensive than cefazolin. Data on vancomycin's impact on resistance are needed to quantify the trade-off between individual patients' improved clinical outcomes and lower costs and the future longterm consequences to society.The emergence of vancomycin-resistant enterococci has opened a new era of hardly treatable bacterial infections, and there is now evidence that more virulent common pathogens such as Staphylococcus aureus can also develop resistance to vancomycin (1,2). The use of vancomycin is hypothesized to promote the development or transmission of this resistance (3,4). Restrictive guidelines have therefore been disseminated for the use of vancomycin or teicoplanin, another glycopeptide agent (5). These guidelines include a recommendation against the routine use of vancomycin as perioperative antibiotic prophylaxis for surgical site infections.However, vancomycin is preferred for preventing infections caused by methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-resistant coagulase-negative staphylococci. This is the rationale for recommending vancomycin prophylaxis when the risk for infection from methicillinresistant pathogens is high (6-11), although no guideline has made a clear statement on when to use this alternative. Since antibiotics are commonly used for prophylaxis, liberal interpretation of the prophylaxis guidelines will clearly jeopardize efforts to limit the use of vancomycin. Vancomycin is also more expensive to purchase and administer than cephalosporins.To inform both the clinical and public policy debate with respect to the optimal prophylaxis regimen, we conducted a cost-effectiveness analysis to compare the short-and longterm consequences of using vancomycin and cefazolin as first-line perioperative prophylaxis. We focused on patients who underwent coronary artery bypass graft surgery (CABG) because this is a large, relatively homogeneous population with substantial risk for serious surgical site infection (12,13). Methods Cost-Effectiveness AnalysisWe developed a decision-analytic model (Figure 1) to calculate the clinical benefits and costs associated with alternative strategies for antibiotic prophylaxis in a hypothetical cohort of 10,000 patients undergoing CAGB surgery. The three strategies evaluated were 1) no prophylaxis; 2) rou...

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Section: Discussionmentioning

confidence: 99%

Section: Clinical Datamentioning

confidence: 99%

Clinical Consequences and Cost of Limiting Use of Vancomycin for Perioperative Prophylaxis: Example of Coronary Artery Bypass Surgery

Zanetti

Goldie

Platt

2001

Emerg. Infect. Dis.

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“…In retrospective placebo-controlled trials it has been shown that antimicrobial prophylaxis did not significantly reduce rate of infection in surgical applications with clean wounds such as augmentation mammoplasty (9), reduction mammoplasty, lumpectomy, mastectomy, and axillary lymph node dissection (19,(22)(23)(24) was concluded that in order to reduce the risk of wound infection, antimicrobial prophylaxis should be used in breast cancer patients undergoing non-reconstructive surgery.…”

Section: Efficiencymentioning

confidence: 99%

Guideline for Antimicrobial Prophylaxis in Breast Surgery

Baghaki¹,

Soybir²,

Soran³

2014

J Breasth Health

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Antimicrobial prophylaxis has an important role in reducing surgical wound infection rates. Besides prophylaxis; basic infection control mechanisms implemented in the clinic (17), the surgeon's experience and technique, duration of operation, hospital and operating room conditions, instrumentation, preoperative preparation including body-washing, skin antisepsis and shaving, peri-operative management of temperature and blood glucose regulation, and the patient's existing co-morbidities all play an important role (16,18). Patient-related risk factors for surgical wound infections are advanced age, negative nutritional status, obesity, diabetes mellitus, cigarette smoking, presence of infection, immunodeficiency or immunosuppressive use, steroid use, recent surgery, long preoperative hospitalization and colonization with microorganisms. MicroorganismsIn breast and plastic surgery procedures, usually S. aureus is responsible for the wound infection (2,6,7,10,11,15,19,20). In axillary region procedures, obese patients prone to maceration, procedures at sweating areas P. aeruginosa, Serratia marcescens, Enterobacteriaceae including E. coli and gram-negatives like Klebsiella can be isolated (20, 21). . Pages 582-667 of this book contain the section:"Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery". This section includes current clinical developments, evidence and recommendations on the application of standard and effective antimicrobial prophylaxis in adult and pediatric patients, and has significant differences compared to the previous 1999 edition. On pages 632-633, antimicrobial prophylaxis in breast and plastic surgery practice is addressed in detail. This article contains a summary of the recommendations made in ASHP 2012/2013 Report regarding the antimicrobial prophylaxis in breast and plastic surgery applications.

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“…A meta-analysis by Platt and colleagues [22] from 1993 analyzed data from 2587 surgical breast procedures and found an overall wound infection rate of 3.8% of cases. Staphylococcal organisms introduced by means of skin flora usually are implicated in these infections [8,17].…”

Section: Wound Infectionsmentioning

confidence: 99%

“…These studies have yielded disparate results; many have shown that a single dose of a preoperative antibiotic (usually a cephalosporin, administered approximately 30 minutes preoperatively) effectively reduces wound infection rates by 40% or more [8,13,21,22], and the meta-analysis by Platt and colleagues [22] revealed that antibiotic prophylaxis reduced wound infection rates by 38%, despite the selection bias of antibiotics being used predominantly in higher-risk cases. Furthermore, the lowest reported rates of breast wound infections occurred in a phase III study [16] of a long-acting versus a short-acting cephalosporin, revealing greater risk reduction with the former (0.45% versus 0.91%).…”

Section: Wound Infectionsmentioning

confidence: 99%

Complications in Breast Surgery

Newman¹,

Sondak²

2007

Surgical Complications

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The breast is a relatively clean organ comprised of skin, fatty tissue, and mammary glandular elements that have no direct connection to any major body cavity or visceral structures. In the absence of concurrent major reconstruction, breast surgery generally is not accompanied by large-scale fluid shifts, infectious complications, or hemorrhage. Thus, most breast operations are categorized as low-morbidity procedures. Because the breast is the site of the most common cancer afflicting American women, however, a variety of complications can occur in association with diagnostic and multidisciplinary management procedures. Some of these complications are related to the breast itself, and others are associated with axillary staging procedures. This article first addresses some general, nonspecific complications (wound infections, seroma formation, hematoma). It then discusses complications that are specific to particular breast-related procedures: lumpectomy (including both diagnostic open biopsy and breast-conservation therapy for cancer), mastectomy; axillary lymph node dissection (ALND), lymphatic mapping/sentinel lymph node biopsy, and reconstruction. Complications related to reconstruction are discussed in a separate article in this issue. General wound complications related to breast and axillary surgeryBecause it is a peripheral soft tissue organ, many wound complications related to breast procedures are relatively minor and frequently are managed on an outpatient basis. It therefore is difficult to establish accurate incidence rates for these events. As discussed later, however, reported studies

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Perioperative antibiotic prophylaxis and wound infection following breast surgery

Cited by 71 publications

References 0 publications

Clinical Consequences and Cost of Limiting Use of Vancomycin for Perioperative Prophylaxis: Example of Coronary Artery Bypass Surgery

Clinical Consequences and Cost of Limiting Use of Vancomycin for Perioperative Prophylaxis: Example of Coronary Artery Bypass Surgery

Guideline for Antimicrobial Prophylaxis in Breast Surgery

Complications in Breast Surgery

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