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Breast Cancer Reconstruction: One dose of antibiotics is not adequate

There is a  trend toward limiting antibiotics to a single dose given before surgery.  A presentation in our plastic surgery society indicates this puts patients who undergo breast reconstruction at a higher risk for infection, reoperation, and consequently, reconstructive failure.

Dr. Halvorson, MD, for UNC in Chapel HIll reports “the use of one dose of perioperative prophylactic antibiotics was associated with a 4-fold increased risk for tissue-expander removal because of infection.”   The finding, from a single-center retrospective cross-sectional study, was presented at Plastic Surgery 2010: Joint Annual Scientific Meeting of the American Society of Plastic Surgery and the Canadian Society of Aesthetic Plastic Surgery.

In the years since I trained in residency, new published studies indicate a single dose of antibiotic, usually given within an hour of surgery starting, is adequate prophylaxis against infection.  “The general surgery literature is replete with advisory statements, guidelines, meta-analyses, and systematic reviews, all of which support this view, and the breast surgery literature has even better data, but when it comes to our own plastic surgery literature, we are left wanting,” said Dr. Halvorson.

After the surgeons decided to adopt the single-dose protocol, Dr. Halvorson and his colleagues noticed infections in their breast reconstruction patients increase, so he asked the question: “Is single-dose perioperative prophylaxis enough?”

  • They compared outcomes in 2 groups of patients — those who received antibiotics before and after surgery (n = 116), and those who received a single dose preoperatively (n = 134), after the new protocol was instituted.
  • They looked for surgical site infections, defined as infections treated with oral or IV antibiotics or with surgery.

Findings? 

  • The rate of infections increased from 19% in the women treated in 2007/08, to 34.3% in those treated in 2009/10 (P = .007).
  • There were no differences in the rates of surgical site infections requiring oral or intravenous antibiotics
  • The rate of infection requiring reoperation increased from 4.3% to 16.4% (P = .002). 
  • The number of tissue-expander surgical site infections increased from 19.6% to 34.3% (P =.024)
  • The number of tissue expanders requiring removal increased from 5.4% to 18.2% (P = .008).
  • Culture results showed a “far more diverse” group of pathogens with the one dose group.

Why?  Why is the rate in our breast reconstruction population seem so different than a general surgery group?  Dr. Halvorson thinks it is from “putting in a large foreign body and covering it with compromised skin flaps” which makes our breast cancer reconstruction patients different than the general surgery patients.

What do I do? I do antibiotics on all of my patients for a week afterwards.  I want to stack the deck in our favor, particularly when my patients are frequently looking at chemo or radiation treatments.

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Please keep in mind: subjects covered in this blog and certain tips and advice are not substitutes for professional medical advice. This blog is for general informational purposes only. If you are considering plastic surgery, reconstructive surgery, or cosmetic enhancement, you should always consult with a board-certified plastic surgeon and/or your general practitioner in-person for professional medical advice.

If you think you may have a medical emergency, call your doctor or (in the United States) 911 immediately. Always seek the advice of your doctor before starting or changing treatment.

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Lauren Greenberg M.D.

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