Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

Abstract

Opinion Statement Surgical site infection (SSI) after immediate breast reconstruction is much more common than would be expected after a clean surgical procedure. Although the SSI rates reported in individual studies are quite variable, there are no obvious explanations for the variation in infection rates between institutions. The microbiology of these SSIs is unusual, with higher proportions of infections caused by atypical Myobacterium species and Gram-negative bacilli than would be expected for this anatomic site. In an effort to prevent SSIs, many surgeons use a variety of different practices including irrigation and soaking of implants with antibiotic solutions and prolonged duration of prophylactic antibiotics, although the literature to support these practices is very sparse. In particular, prolonged use of antibiotics post-discharge is concerning due to the potential for harm, including increased risk of Clostridium difficile infection, development of antibiotic resistant organisms, and drug-related allergic reactions. With higher rates of mastectomy and breast implant reconstruction in women with early-stage breast cancer, including greater utilization of reconstruction in higher-risk individuals, the number of women suffering from infection after oncologic reconstruction will likely continue to increase. It is imperative that more research be done to identify modifiable factors associated with increased risk of infection. It is also essential that larger studies with rigorous study designs be performed to identify optimal strategies to decrease the risk of SSI in this vulnerable population.

The relationship between post-surgery infection and breast cancer recurrence

“…There is evidence that specific bacterial species are associated with SSI from the breast surgical wound of the cancer patients. S. aureus, E. coli and P. aeruginosa were the most common causative bacterial species identified, consistent with emerging literature [165]. There was a high proportion of DRs.…”

Prevalence and Predictors of Postdischarge Antibiotic Use Following Mastectomy

“…In the study by Avashia et al, 28 a change in prophylactic antibiotic practice was prompted by a 31.6% infection rate in 19 women during the period when only perioperative antibiotics were used, raising the possibility that the decreased SSI rate after reverting back to prolonged antibiotic administrative was due to regression to the mean. The 5 observational studies 10 , 29 – 32 and 1 randomized trial 33 in the literature that did not find significantly different SSI rates associated with postdischarge antibiotic use compared to 24 hours or less of antibiotic administration were small and thus underpowered to detect a significant difference if it existed 34 . The lack of high-quality data on the risk and benefits of postdischarge antibiotic prophylaxis likely perpetuates the continued use of inappropriate prolonged antibiotic prophylaxis beyond the recommended 24 hours of duration.…”

Plastic and reconstructive surgical procedures should be incorporated into the surgical site infection (SSI) surveillance programme across Scotland

“…The health impact and decreased quality of life from the complications of SSI after breast reconstruction, skin graft, amputation and lymphadenectomy have been emphasised in recent literature ( Olsen et al, 2017 ; Onyekwelu et al, 2017 ; Palubicka et al, 2019 ). Surgical reconstructive procedures with autograft or breast implants after mastectomy is aimed at enhancing body image.…”

“…Surgical reconstructive procedures with autograft or breast implants after mastectomy is aimed at enhancing body image. According to Olsen et al (2017) , the rate of SSI in mastectomy without immediate reconstruction was 3%–18%, compared to 0.4%–17% and 1%–12% for mastectomy with implant reconstruction and autologous flap reconstruction, respectively. The higher rate of SSI after mastectomy could be a result of lengthy operative time and accumulation of serous fluid which serves as a source of nutrients for microorganisms.…”

“…The higher rate of SSI after mastectomy could be a result of lengthy operative time and accumulation of serous fluid which serves as a source of nutrients for microorganisms. Although reconstruction can be carried out 3–6 months after mastectomy, rates of SSI after immediate implant reconstruction or autologous flap reconstruction were in the range of < 1% to > 10% ( Olsen et al, 2017 ). It can be further speculated that the huge disparities between the rate of SSI in breast reconstruction suggests the need for a strict surveillance system and follow-up after discharge.…”