Prevalence and Predictors of Postdischarge Antibiotic Use Following Mastectomy

Abstract

Objective Surveys suggest prolonged administration of prophylactic antibiotics is common after mastectomy with reconstruction. We determined utilization, predictors, and outcomes of post-discharge prophylactic antibiotics after mastectomy ± immediate breast reconstruction. Design Retrospective cohort. Patients Commercially insured women aged 18–64 years coded for mastectomy from 1/2004–12/2011. Women with a preexisting wound complication or septicemia were excluded. Methods Predictors of prophylactic antibiotics within 5 days after discharge were identified in women with one year prior insurance enrollment; relative risks (RR) were calculated using generalized estimating equations. Results 12,501 mastectomy procedures were identified, with immediate reconstruction in 7,912 (63.3%). Post-discharge prophylactic antibiotics were used in 4,439 (56.1%) procedures with and 1,053 (22.9%) without immediate reconstruction (p < .001). The most common antibiotics were cephalosporins (75.1%) and fluoroquinolones (11.1%). Independent predictors of post-discharge antibiotics were implant reconstruction (RR 2.41, 95% confidence interval [CI] 2.23, 2.60), autologous reconstruction (RR 2.17, 95% CI 1.93, 2.45), autologous reconstruction plus implant (RR 2.11, 95% CI 1.92, 2.31), hypertension (RR 1.05, 95% CI 1.00, 1.10), tobacco use (RR 1.07, 95% CI 1.01, 1.14), surgery at an academic hospital (RR 1.14, 95% CI 1.07, 1.21), and receipt of home health care (RR 1.11, 95% CI 1.04, 1.18). Post-discharge prophylactic antibiotics were not associated with SSI after mastectomy ± immediate reconstruction (both p > 0.05). Conclusions Prophylactic post-discharge antibiotics are common after mastectomy, with immediate reconstruction the strongest predictor. Stewardship efforts in this population to limit continuation of prophylactic antibiotics after discharge are needed to limit antimicrobial resistance.

Prophylactic Antibiotics for Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Comparison between Three Different Duration Approaches

“…Furthermore, these guidelines state that perioperative antibiotic prophylaxis to prevent SSI should not be continued due to the presence of a wound drain, because extended antibiotic usage could lead to the development of resistant organisms and systemic side effects, including severe allergic reactions, pseudomembranous colitis ( Clostridim difficile infection), and yeast infection. 14 , 15 In Olsen’s study, 13 0.1% procedures among 12,198 patients had evidence of Clostridium difficile infection after mastectomy with or without immediate reconstruction. In contrast, the American Society of Healthcare System Pharmacists and the United States Institute for Healthcare Improvement recommend discontinuation of antibiotic prophylaxis within 24 hours of clean and clean/contaminated surgery.…”

“… 11 In a survey that interviewed 460 plastic surgeons, 72% of them prescribed outpatient antibiotics after mastectomy with breast reconstruction. 12 In Olsen’s study, 13 5492 of 12,501 (43.9%) mastectomy procedures had prophylactic antibiotics after discharge in 5 days, and cephalosporins (75.1%) were the most commonly prescribed antibiotics.…”

Postdischarge prophylactic antibiotics following mastectomy with and without breast reconstruction

“…11,17 More recently, 2 adequately powered studies using administrative claims data showed no association of continued prophylactic antibiotics with decreased SSI risk after mastectomy plus reconstruction. 18,19 Only 2 prior studies have evaluated postdischarge prophylactic antibiotic use in the mastectomy-only population. The study by Edwards et al 10 is subject to confounding bias because surgeries were performed by 2 surgeons, with one utilizing only preoperative antibiotics and the other continuing antibiotics after discharge.…”

“…11 Conversely, numerous studies demonstrated no effect of postdischarge antibiotics on SSI following mastectomy, although many of these studies lacked sufficient power to detect an association with only a moderate effect. [12][13][14][15][16][17][18][19][20][21] Exposure of patients to prolonged antibiotic regimens results in higher costs, selection of antibiotic-resistant organisms, and increased risk of Clostridioides difficile infection. [22][23][24][25][26] The importance of outpatient antibiotic stewardship is increasingly recognized because outpatient antibiotic prescriptions constitute the majority of antibiotic use.…”

Effectiveness of Single vs Multiple Doses of Prophylactic Intravenous Antibiotics in Implant-Based Breast Reconstruction

“…Even though a single preoperative antibiotic dose offers sufficient SSI prevention in breast augmentation surgery, 35 extended antibiotic prophylaxis is commonly given. 36 , 37 It is important to consider in the context of an increased risk of acquired antibiotic resistance through extended antibiotic prophylaxis. 20 The main aim of this prospective randomized clinical trial was to investigate whether single-dose or multiple-dose antibiotic prophylaxis is most effective in preventing implant removal and reducing SSI rates.…”