What is the treatment for breast implant infections or exposures?

Treatment of Breast Implant Infections or Exposures

For breast implant infections, immediate broad-spectrum intravenous antibiotics targeting methicillin-resistant staphylococci and gram-negative organisms should be initiated, with implant explantation reserved for severe infections or failed antibiotic therapy, as salvage rates exceed 75% with aggressive medical management in mild-to-moderate cases.

Initial Assessment and Antibiotic Selection

Severity Classification

The treatment approach depends critically on infection severity:

• Mild infection (cellulitis without systemic signs): Start oral fluoroquinolones (levofloxacin or ciprofloxacin) as first-line therapy based on institutional susceptibility patterns showing 80-86% sensitivity 1
• Severe infection (systemic signs, gross purulence, or sepsis): Initiate intravenous broad-spectrum antibiotics immediately 2

Empiric Antibiotic Regimens

The most common causative organisms are methicillin-resistant staphylococci (44%) and gram-negative pathogens (26%), including Pseudomonas (13%) and Klebsiella (5%) 3. Based on this microbiology:

• First-line IV therapy: Daptomycin combined with piperacillin-tazobactam covers both resistant gram-positive and gram-negative organisms 4
• Alternative regimens: Vancomycin plus gentamicin, or imipenem monotherapy if fluoroquinolones fail 1
• Duration: Average 18 days of IV therapy (range 1-40 days depending on clinical response) 4

Critical caveat: Avoid extending postoperative prophylactic antibiotics beyond 24 hours, as this does not reduce infection rates and promotes multidrug-resistant organisms 3

Surgical Management Algorithm

For Mild Infection Without Exposure

1. Start oral fluoroquinolones immediately 1
2. If no improvement within 48-72 hours, escalate to IV antibiotics 2
3. Consider operative intervention if infection persists despite appropriate antibiotics 2

For Threatened or Actual Exposure (Without Severe Infection)

Salvage rate is 90.9% with aggressive intervention 2:

• Remove implant temporarily 2
• Perform pocket curettage and pulse lavage 2
• Consider partial or total capsulectomy 2
• Débride all nonviable tissue 2
• Exchange device if tissues are healthy 2
• Primary closure or flap coverage as needed 2
• Continue IV antibiotics throughout perioperative period 2

For Severe Infection

Salvage rate drops to 28.6% with severe infection 2:

• Explant immediately if gross purulence, overwhelming infection, or marginal soft tissue coverage 2
• Do not attempt immediate salvage 2
• Administer IV antibiotics for minimum 3 months for atypical mycobacterial infections 5
• Delay reimplantation until complete infection resolution (typically 3-6 months) 5

Specific Clinical Scenarios

Implant Exposure Without Clinical Infection

• 90% salvage rate achievable 2
• Débride exposed capsule 2
• Exchange implant 2
• Provide healthy tissue coverage (local flap or acellular dermal matrix) 2
• Prophylactic antibiotics perioperatively 2

Atypical Mycobacterial Infections

These require distinct management:

• Explant all hardware immediately 5
• Triple antibiotic therapy: clarithromycin + gatifloxacin + linezolid for 3 months 5
• Reimplantation only after 3-month antibiotic course completion 5
• Continue antibiotics for 6 weeks post-reimplantation 5
• Most common organisms: Mycobacterium fortuitum and M. chelonei 5

Monitoring and Complications of Antibiotic Therapy

Expected Adverse Events

With broad-spectrum IV antibiotics, 35% of patients experience adverse events 4:

• Diarrhea (12.6%) 4
• Rash (10%) 4
• Agranulocytosis/neutropenic fever (3.6%) - requires immediate discontinuation 4
• Vascular access complications: DVT (1.8%), line occlusion (1.8%) 4

Treatment Discontinuation

Only 4% require antibiotic discontinuation due to severe adverse events 4. When discontinuation occurs, explantation is typically necessary 4.

Salvage vs. Explantation Decision-Making

Key determinant: Infection severity creates statistically significant outcome differences (p = 0.0017) 2

• Mild infection or no infection: 94.7% salvage success rate 2
• Severe infection: Only 28.6% salvage success rate 2

Factors Favoring Explantation

• Gross purulence 2
• Systemic sepsis 2
• Marginal or necrotic soft tissue coverage 2
• Failed antibiotic therapy after 7-10 days 2
• Atypical mycobacterial infection (temporary explantation) 5

Factors Favoring Salvage Attempt

• Mild cellulitis responsive to oral antibiotics 1, 2
• Adequate soft tissue coverage available 2
• Early detection (within 48 hours of symptom onset) 3
• Patient compliance with prolonged IV therapy 4

Reconstruction After Infection Resolution

For patients requiring explantation, reconstruction options include:

• Delayed implant-based reconstruction: After complete infection resolution 5
• Autologous flap reconstruction: Consider for high-risk patients, as infection rate is lower (7% vs 13%) 3
• Timing: Minimum 3 months for bacterial infections, 3-6 months for atypical mycobacteria 5

Important pitfall: Seromas between acellular dermal matrix and implants are isolated from immune surveillance and increase infection risk (RR 2.47,95% CI 1.71-3.57) 3. Remove drains when output <30 mL/day, not exceeding 7-14 days 3.