Evaluation of Current Perioperative Antimicrobial Regimens for the Prevention of Surgical Site Infections in Breast Implant-Based Reconstructive Surgeries

George M. Viola, MD, MPH; Kenneth V. Rolston, MD; Charles Butler, MD; Jesse Selber, MD; Gregory Reece, MD; Mark Clemens, MD; Mark Villa, MD; Issam I. Raad, MD; Donald Baumann, MD


Plast Reconstr Surg Glob Open. 2019;7(7):e2342 

In This Article

Abstract and Introduction


Background: Several steps to reduce the rate of postoperative surgical site infections (SSIs) have been implemented. The use of prophylactic antimicrobials targeting patient's microbial flora has been associated with a decrease in postoperative infections. We evaluated the relationship between perioperative antimicrobials, baseline microbial flora, and occurrence of SSIs.

Methods: We prospectively enrolled 241 patients scheduled to receive a postmastectomy implant-based reconstructive procedure between September 2015 and January 2018. Axillary swab cultures were obtained preoperatively, and all recovered bacteria were identified. Surgeons were blinded to these results. The use of prophylactic perioperative antimicrobials was defined as concordant if the baseline axillary flora were susceptible to the given antibiotic and discordant if not. As Staphylococcus species are the most common pathogen causative for breast implant-related infections, patients colonized with these organisms were analyzed in detail. All patients were followed up for at least 6 months postoperatively and evaluated for SSIs.

Results: A total of 238 patients (99%) received both perioperative and postoperative oral antimicrobials. The most common preoperative staphylococci axillary flora recovered were methicillin-sensitive coagulase-negative Staphylococcus (67%), methicillin-resistant coagulase-negative Staphylococcus (35%), with only 1 case of methicillin-sensitive Staphylococcus aureus (0.4%). Thirty-three patients (14%) developed an SSI. Of those with a positive Staphylococcus culture, only 54% received a concordant antimicrobial regimen, but this was not associated with an increased risk for infection (P > 0.72).

Conclusions: The use of perioperative antimicrobials whether concordant or discordant with the preoperative axillary microbial flora, specifically Staphylococci species, did not provide a significant impact on the risk of SSI.


The rate of breast cancer surgery has increased through the years, mainly due to the use of improved methods of cancer detection, such as radiological and genetic testing. Simultaneously, due to improved favorable economic factors, improvements in implant design, and the widespread successful use of acellular dermal matrix (ADM), breast reconstruction with tissue expanders (TEs) and implants is becoming increasingly popular among patients who have undergone mastectomy due to breast cancer prevention or treatment.[1,2] The American Society of Plastic Surgeons reported that, in 2017, its members performed approximately 106,000 breast reconstructive procedures in the United States alone.[3] Of these patients, approximately 74,000 underwent breast reconstruction with TEs and implants, whereas the remaining patients had autologous reconstructions.

Unfortunately, the rate of infection after breast implant reconstruction, which varies by hospital and region, remains unacceptably high, ranging from 2.5% to 24%.[4–6] Infections that do not respond to antibiotic treatment alone usually require further surgery and explantation of the device, which is devastating for both patients and physicians.

Randomized controlled studies have demonstrated that prophylactic antibiotics are effective in preventing surgical wound infections.[7] However, the most frequently utilized perioperative antimicrobials, mainly first-generation cephalosporins, do not cover commonly encountered skin pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative Staphylococcus resistant to methicillin (CNS-R), which are responsible for over two-thirds of all breast implant-related infections.[8] The baseline skin and axillary microbial flora that are contiguous with the surgical incision site and the axillary surgical drains, which usually remain in place for 1–2 weeks, are the pathogens most likely to cause a surgical site infection (SSI).[9] Therefore, selecting targeted, prophylactic perioperative antimicrobials on the basis of patients' baseline microbial skin flora, instead of following a standard empirical "one size fits all" approach, seems a reasonable means of reducing SSIs. Several studies have demonstrated that the use of targeted perioperative antimicrobials, concordant with patients baseline microbial flora, has been associated with a decrease in postoperative SSI.[10,11] We conducted this prospective observational study of patients undergoing postmastectomy implant-based reconstructive procedures to determine whether the use of antimicrobial prophylaxis concordant with patients' baseline axillary microbial flora reduces the risk of postsurgical site infections.