Once is not enough: withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of infection.

Surgical-site infection is a potential complication for all surgical procedures and is one of the leading causes of morbidity for postmastectomy breast reconstruction.1–3 Surgical-site infections have been reported in approximately 2 percent of patients undergoing postmastectomy implant breast reconstruction.2 Although this rate has varied widely in a number of different studies,4 it likely represents infections that required implant removal. Infections can range from mild cellulitis requiring oral antibiotics to more severe cellulitis resolving with inpatient intravenous antibiotics to frank abscess formation requiring implant removal, and thus the actual rates of infection, if defined more broadly, may be much higher. Most plastic surgeons prescribe preoperative prophylactic antibiotics for patients undergoing breast reconstruction and continue perioperative prophylactic antibiotics administered intravenously during hospitalization and orally on discharge until a set time (e.g., 7 days) or until drains are removed.5 This practice has been prone to criticism by infection control officers and others who quote data from studies6–11 suggesting that, despite the increasing use of prophylactic antibiotics, there has been no corresponding decrease in rates of infection postoperatively. However, Hawn and colleagues12 recently examined the efficacy of improved adherence to the Surgical Care Improvement Project guidelines and noted stable rates of surgical-site infection at the patient and hospital levels despite increased use of preoperative prophylactic antibiotics and decreased use of postoperative prophylactic antibiotics. These studies would suggest that prolonged (>24 hours) postoperative prophylactic antibiotics are not indicated for routine clean surgical procedures. At our university-affiliated tertiary care center, guidelines governing the use of perioperative antibiotic prophylaxis were implemented in October of 2008 based on pay-for-performance incentives and the Surgical Care Improvement Project. Our Division made a decision to adopt evidence-based perioperative antibiotic prophylaxis guidelines and in January of 2009 began prescribing a single pre-operative dose for all patients undergoing breast reconstruction. Patients undergoing lengthy operations (e.g., perforator flap) were given additional intraoperative doses as indicated. Although the Surgical Care Improvement Project protocol permitted up to 24 hours of postoperative antibiotics, our group made a decision not to give any postoperative prophylactic antibiotics in an effort to engage in strictly evidence-based medicine. In the ensuing year, an increase in the rate of postoperative surgical-site infection was noted in patients undergoing breast reconstruction, particularly those undergoing prosthetic reconstruction. This prompted a review of our experience before and after the Surgical Care Improvement Project protocol was instituted to determine whether or not the change in perioperative antibiotic prophylaxis regimen was associated with an increased risk of surgical-site infection. We hypothesized that patients receiving postoperative prophylactic antibiotics would have decreased postoperative infection rates compared with patients who received only perioperative antibiotics according to the Surgical Care Improvement Project protocol.