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Breast Tissue Expander—Related Infections: Perioperative Antimicrobial Regimens

Published online by Cambridge University Press:  10 May 2016

George M. Viola*
Division of Medicine, Department of Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
Issam I. Raad
Division of Medicine, Department of Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
Kenneth V. Rolston
Division of Medicine, Department of Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1460, Houston, TX 77030 (



The rate of postmastectomy tissue expander (TE) infection remains excessively high, ranging between 2% and 24%. We hypothesized that current perioperative antimicrobial regimens utilized for breast TE reconstruction may be outdated as a result of recent changes in microflora and susceptibility patterns.

Design and Methods.

We reviewed the records of all patients who had a TE reconstructive procedure and developed a definite breast TE infection between 2003 and 2010 at MD Anderson Cancer Center. Antimicrobials were stratified into 3 groups: systemic perioperative, local irrigation, and oral immediate postoperative antimicrobials. These were considered discordant if they did not target the isolated organisms, while a breakthrough infection was defined as an infection that occurred despite concordant antimicrobial coverage.


Overall, 75 patients with a definite TE infection were identified. The most common organisms identified were methicillin-resistant Staphylococcus epidermidis (29%), methicillin-resistant Staphylococcus aureus (15%), and gram-negative rods (26%). The use of systemic perioperative antimicrobials was deemed discordant in 51% of the cases. Although 79% of the patients received broad-spectrum perioperative local antimicrobial irrigation, 63% developed a breakthrough infection. Even though 61% received oral postoperative prophylactic antimicrobials, 63% of the times they were deemed discordant.


Contrary to the proven effectiveness of a single dose of perioperative antibiotics, the common use of local antimicrobial irrigation and prolonged postoperative oral antibiotics appears to be an inadequate component of our preventive armamentarium. Also, because methicillin-resistant staphylococcal and pseudomonal infections occurred approximately 60% of the time, at institutions that have observed an increase of these organisms, it may be prudent that perioperative antimicrobials target these microorganisms.

Original Article
Copyright © The Society for Healthcare Epidemiology of America 2014

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1. McGuire, KP, Santillan, AA, Kaur, P, et al. Are mastectomies on the rise? a 13-year trend analysis of the selection of mastectomy versus breast conservation therapy in 5865 patients. Ann Surg Oncol 2009;16(10):26822690.CrossRefGoogle Scholar
2. Damie, S, Teal, CB, Lenert, JJ, Marshall, EC, Pan, Q, McSwain, AP. Mastectomy and contralateral prophylactic mastectomy rates: an institutional review. Ann Surg Oncol 2011;18(5):13561363.Google Scholar
3. Warren Peled, A, Itakura, K, Foster, RD, et al. Impact of chemotherapy on postoperative complications after mastectomy and immediate breast reconstruction. Arch Surg 2010;145(9):880885.CrossRefGoogle ScholarPubMed
4. American Society of Plastic Surgeons (ASPS). 2012 Plastic Surgery Statistics Report. Arlington Heights, IL: ASPS, 2012. Accessed August 2, 2013.Google Scholar
5. Halvorson, EG, Disa, JJ, Mehrara, BJ, Burkey, BA, Pusic, AL, Cordeiro, PG. Outcome following removal of infected tissue expanders in breast reconstruction: a 10-year experience. Ann Plast Surg 2007;59(2):131136.CrossRefGoogle ScholarPubMed
6. Radovan, C. Breast reconstruction after mastectomy using the temporary expander. Plast Reconstr Surg 1982;69(2):195208.CrossRefGoogle ScholarPubMed
7. Nahabedian, MY, Tsangaris, T, Momen, B, Manson, PN. Infectious complications following breast reconstruction with expanders and implants. Plast Reconstr Surg 2003;112(2):467476.CrossRefGoogle ScholarPubMed
8. Pittet, B, Montandon, D, Pittet, D. Infection in breast implants. Lancet Infect Dis 2005;5(2):94106.CrossRefGoogle ScholarPubMed
9. Khan, UD. Breast augmentation, antibiotic prophylaxis, and infection: comparative analysis of 1,628 primary augmentation mammoplasties assessing the role and efficacy of antibiotics prophylaxis duration. Aesthetic Plast Surg 2010;34(1):4247.CrossRefGoogle ScholarPubMed
10. Horan, TC, Andrus, M, Dudeck, MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36(5):309332.CrossRefGoogle ScholarPubMed
11. Bratzier, DW, Dellinger, EP, Olsen, KM. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70(3):195283.CrossRefGoogle Scholar
12. Cordeiro, PG, McCarthy, CM. A single surgeon's 12-year experience with tissue expander/implant breast reconstruction. I. A prospective analysis of early complications. Plast Reconstr Surg 2006;118(4):825831.CrossRefGoogle ScholarPubMed
13. Armstrong, RW, Berkowitz, RL, Bolding, F. Infection following breast reconstruction. Ann Plast Surg 1989;23(4):284288.CrossRefGoogle ScholarPubMed
14. Spear, SL, Majidian, A. Immediate breast reconstruction in two stages using textured, integrated-valve tissue expanders and breast implants: a retrospective review of 171 consecutive breast reconstructions from 1989 to 1996. Plast Reconstr Surg 1998;101(1):5363.CrossRefGoogle ScholarPubMed
15. Francis, SH, Ruberg, RL, Stevenson, KB. Independent risk factors for infection in tissue expander breast reconstruction. Plast Reconstr Surg 2009;124(6):17901796.CrossRefGoogle ScholarPubMed
16. Handel, N, Jensen, JA, Black, Q, Waisman, JR, Silverstein, MJ. The fate of breast implants: a critical analysis of complications and outcomes. Plast Reconstr Surg 1995;96(7):15211533.CrossRefGoogle ScholarPubMed
17. Disa, JJ, Ad-El, DD, Cohen, SM, Cordeiro, PG, Hidalgo, DA. The premature removal of tissue expanders in breast reconstruction. Plast Reconstr Surg 1999;104(6):16621665.CrossRefGoogle ScholarPubMed
18. Cordeiro, PG, Pusic, AL, Disa, JJ, McCormick, B, VanZee, K. Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg 2004;13(3):877881.CrossRefGoogle Scholar
19. Araco, A, Gravante, G, Araco, F, Delogu, D, Cervelli, V, Walgenbach, K. Infections of breast implants in aesthetic breast augmentations: a single-center review of 3,002 patients. Aesthetic Plast Surg 2007;31(4):325329.CrossRefGoogle ScholarPubMed
20. Degnim, AC, Scow, JS, Hoskin, TL, et al. Randomized controlled trial to reduce bacterial colonization of surgical drains after breast and axillary operations. Ann Surg 2013;258(2):240247.CrossRefGoogle ScholarPubMed
21. Vandeweyer, E, Deraemaecker, R, Nogaret, JM, Hertens, D. Immediate breast reconstruction with implants and adjuvant chemotherapy: a good option? Acta Chir Belg 2003;103(1):98101.CrossRefGoogle ScholarPubMed
22. Piper, M, Peled, AW, Foster, RD, Moore, DH, Esserman, LJ. Total skin-sparing mastectomy: a systematic review of oncologic outcomes and postoperative complications. Ann Plast Surg 2013.CrossRefGoogle ScholarPubMed
23. Reish, RG, Damjanovic, B, Austen, WG Jr, et al. Infection following implant-based reconstruction in 1952 consecutive breast reconstructions: salvage rates and predictors of success. Plast Reconstr Surg 2013;131(6):12231230.CrossRefGoogle ScholarPubMed
24. Mortenson, MM, Schneider, PD, Khatri, VP, et al. Immediate breast reconstruction after mastectomy increases wound complications: however, initiation of adjuvant chemotherapy is not delayed. Arch Surg 2004;139(9):988991.CrossRefGoogle Scholar
25. Tejirian, T, DiFronzo, LA, Haigh, PI. Antibiotic prophylaxis for preventing wound infection after breast surgery: a systematic review and metaanalysis. J Am Coll Surg 2006;203(5):729734.CrossRefGoogle ScholarPubMed
26. Throckmorton, AD, Hoskin, T, Boostrom, SY, et al. Complications associated with postoperative antibiotic prophylaxis after breast surgery. Am J Surg 2009;198(4):553556.CrossRefGoogle ScholarPubMed
27. Bratzler, DW, Houck, PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg 2005;189(4):395104.CrossRefGoogle ScholarPubMed
28. Feldman, EM, Kontoyiannis, DP, Sharabi, SE, Lee, E, Kaufman, Y, Heller, L. Breast implant infections: is cefazolin enough? Plast Reconstr Surg 2010;126(3):779785.CrossRefGoogle Scholar
29. Phillips, BT, Wang, ED, Mirrer, J, Lanier, ST, Khan, SU, Dagum, AB, Bui, DT. Current practice among plastic surgeons of antibiotic prophylaxis and closed-suction drains in breast reconstruction: experience, evidence, and implications for postoperative care. Ann Plast Surg 2011;66(5):460465.CrossRefGoogle ScholarPubMed
30. Mangram, AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR; Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20(4):250278.CrossRefGoogle ScholarPubMed
31. Adams, WP Jr, Conner, WC, Barton, FE Jr, Rohrich, RJ. Optimizing breast-pocket irrigation: the post-betadine era. Plast Reconstr Surg 2001;107(6):15961601.CrossRefGoogle ScholarPubMed
32. Adams, WP Jr, Conner, WC, Barton, FE Jr, Rohrich, RJ. Optimizing breast pocket irrigation: an in vitro study and clinical implications. Plast Reconstr Surg 2000;105(1):334338.CrossRefGoogle Scholar
33. Adams, WP Jr, Rios, JL, Smith, SJ. Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr Stirg 2006;118(7 suppl):46S52S.CrossRefGoogle ScholarPubMed
34. Pfeiffer, P, Jorgensen, S, Kristiansen, TB, Jorgensen, A, Holmich, LR. Protective effect of topical antibiotics in breast augmentation. Plast Reconstr Surg 2009;124(2):629634.CrossRefGoogle ScholarPubMed
35. Washer, LL, Gutowski, K. Breast implant infections. Infect Dis Clin North Am 2012;26(1):111125.CrossRefGoogle ScholarPubMed
36. Zanetti, G, Goldie, SJ, Piatt, R. Clinical consequences and cost of limiting use of vancomycin for perioperative prophylaxis: example of coronary artery bypass surgery. Emerg Infect Dis 2001;7(5):820827.CrossRefGoogle ScholarPubMed
37. Elliott, RA, Weatherly, HL, Hawkins, NS, et al. An economic model for the prevention of MRSA infections after surgery: non-glycopeptide or glycopeptide antibiotic prophylaxis? Eur J Health Econ 2010;11(1):5766.CrossRefGoogle ScholarPubMed
38. Cranny, G, Elliott, R, Weatherly, H, et al. A systematic review and economic model of switching from non-glycopeptide to glycopeptide antibiotic prophylaxis for surgery. Health Technol Assess 2008;12(1): iii-iv, xi-xii, 1147.CrossRefGoogle ScholarPubMed
39. Crawford, T, Rodvold, KA, Solomkin, JS. Vancomycin for surgical prophylaxis? Clin Infect Dis 2012;54(10):14741479.CrossRefGoogle ScholarPubMed
40. Alexander, JW, Solomkin, JS, Edwards, MJ. Updated recommendations for control of surgical site infections. Ann Surg 2011;253(6):10821093.CrossRefGoogle ScholarPubMed
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