Management of Surgical Site Infection After Breast Reduction
For established surgical site infections after breast reduction, promptly open the wound to drain purulent material and initiate therapeutic antibiotics targeting both gram-positive cocci (particularly Staphylococcus) and gram-negative organisms, as nearly half of breast SSIs are caused by gram-negative bacteria. 1, 2
Immediate Wound Management
- Open and drain the infected wound immediately if purulent drainage, erythema, or fluctuance is present, as this is the cornerstone of SSI treatment 3
- Remove any sutures or staples overlying the infected area to allow adequate drainage 3
- Perform wound irrigation and debridement of any necrotic tissue 3
- Pack the wound loosely with saline-moistened gauze and plan for delayed closure or healing by secondary intention 3
Antibiotic Selection for Established SSI
The choice of antibiotics must differ from prophylactic regimens because breast SSIs have distinct microbiology:
- Gram-negative bacteria cause 49% of breast SSIs, with 13-17.5% of all isolates being resistant to cefazolin 1
- Staphylococcus species (including S. aureus) account for approximately 54% of infections, with methicillin-resistant strains being rare (only 2% in one series) 1, 2
- Polymicrobial infections occur in 15% of cases 1
Recommended Empiric Antibiotic Regimen
For therapeutic treatment (not prophylaxis), initiate broad-spectrum coverage:
- First-line option: Cefazolin 1-2 grams IV every 8 hours PLUS an aminoglycoside (gentamicin) for gram-negative coverage 4
- Alternative: A second-generation cephalosporin with better gram-negative coverage (e.g., cefoxitin or cefotetan) as monotherapy 4
- Continue antibiotics for 5-7 days if systemic signs are present (fever, tachycardia, hypotension) 5, 4
- If only localized infection without systemic involvement, antibiotics may be discontinued once adequate drainage is achieved and local signs resolve 5
Obtain Cultures Before Antibiotic Initiation
- Always obtain wound cultures before starting antibiotics to guide subsequent therapy 4, 2
- Adjust antibiotic coverage based on culture results and sensitivities 4, 2
- Gram-positive isolates from breast surgery show 100% susceptibility to beta-lactams (except penicillin) but reduced susceptibility to macrolides and lincosamides 2
Systemic Signs Requiring Aggressive Management
Escalate care immediately if any of the following are present:
- Hypotension, oliguria, or altered mental status indicating sepsis 5
- Fever >38.5°C with tachycardia 5
- Rapidly spreading erythema suggesting necrotizing infection 3
- These patients require hospital admission, IV antibiotics, and possible surgical debridement 5
Risk Factors and Prevention Context
While managing the current infection, recognize that certain procedures carry higher SSI risk:
- Subcutaneous mastectomy with prosthetic reconstruction has 14.6% SSI rate 2
- TRAM flap reconstruction has 14.3% SSI rate 2
- Simple reduction mammoplasty has lower baseline risk (2.35-6.2%) 2, 6
- Resection weight and diabetes mellitus increase wound healing disturbances 6
Critical Pitfalls to Avoid
- Do not rely on cefazolin monotherapy for established SSI, as 13-17.5% of breast isolates are resistant and half are gram-negative 1
- Do not confuse prophylaxis with treatment: prophylactic antibiotics should stop within 24 hours post-operatively; established SSI requires therapeutic dosing and duration 5, 4
- Do not delay wound opening in favor of antibiotic therapy alone—drainage is essential 3
- Do not assume MRSA is common in breast SSI (only 2% prevalence), so routine vancomycin is unnecessary unless local epidemiology suggests otherwise 1
Adjunctive Measures for Complex Cases
- Consider negative-pressure wound therapy (NPWT) for large wounds or those at high risk of dehiscence, as it reduces SSI rates by 58% and wound dehiscence by 29% when used prophylactically 3
- For contaminated wounds requiring delayed closure, NPWT combined with delayed closure reduces SSI from 37% to 0% compared to primary closure 3