What is the role of antibiotic prophylaxis in preventing surgical site infections (SSIs) after breast reconstruction surgery?

From the Guidelines

Breast reconstruction patients are at risk for surgical site infections, and antibiotic prophylaxis is recommended to mitigate this risk. A first-generation cephalosporin, such as cefazolin, is commonly administered at a dose of 1-2 grams intravenously within 60 minutes prior to surgical incision, with redosing every 4 hours as needed 1. For patients with a penicillin allergy, clindamycin or vancomycin may be used as alternative prophylactic agents, with dosing regimens of 600-900 mg intravenously and 1-2 grams intravenously, respectively.

Key Considerations

• The duration of antibiotic prophylaxis should not exceed 24 hours 1.
• Skin preparation with chlorhexidine-alcoholic solution is associated with a lower rate of surgical site infections, compared to povidone-iodine solution 1.
• The choice of antibiotic should be dependent upon local guidelines, and should be different from the drug of choice for treatment of established infections 1.
• Repeated intraoperative doses may be necessary depending on the half-life of the drug and duration of the procedure 1.

Best Practices

• Administer antibiotics within 1 hour of skin incision 1.
• Use broad-spectrum intravenous antibiotics for emergency laparotomy 1.
• Consider normothermia and control of blood glucose to reduce surgical site infections 1.

From the FDA Drug Label

To prevent postoperative infection in contaminated or potentially contaminated surgery, recommended doses are: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery. The prophylactic administration of cefazolin for injection may be continued for 3 to 5 days following the completion of surgery. The prophylactic administration of Cefazolin for Injection, USP preoperatively, intraoperatively, and postoperatively may reduce the incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated

The role of antibiotic prophylaxis, specifically cefazolin, in preventing surgical site infections (SSIs) after breast reconstruction surgery is to reduce the incidence of postoperative infections.

• The recommended dose is 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery.
• The prophylactic administration of cefazolin may be continued for 3 to 5 days following the completion of surgery, depending on the type of surgery and the risk of infection 2 2. Key points:
• Cefazolin is used to prevent postoperative infection in contaminated or potentially contaminated surgery.
• The dosage and duration of cefazolin administration may vary depending on the type of surgery and the risk of infection.

From the Research

Role of Antibiotic Prophylaxis in Preventing SSIs

• The use of antibiotic prophylaxis in preventing surgical site infections (SSIs) after breast reconstruction surgery has been studied extensively 3, 4, 5, 6, 7.
• A study published in 2016 found that the administration of extended prophylactic antibiotics does not reduce the overall risk of SSI after expander-based breast reconstruction, but may influence antibiotic resistance patterns when infections occur 3.
• Another study published in 2022 found that short-course perioperative antibiotic prophylaxis (≤24 hours) is not inferior to treatment for more than 24 hours in preventing postoperative surgical-site infections in immediate implant-based breast reconstruction 4.

Duration of Antibiotic Prophylaxis

• Research suggests that prolonging antibiotic prophylaxis beyond 24 hours does not reduce the risk of SSIs in breast reconstruction surgery 4, 5, 6.
• A systematic review published in 2023 found that antibiotic prophylaxis up to a maximum of 24 hours is useful in lowering infection rates in autologous breast reconstructions 5.
• A study published in 2012 found that the duration of postoperative antibiotic use did not differ in patients who developed surgical-site infections, and that there was no reduction in the overall surgical-site infection rate among autologous breast reconstruction patients who received postoperative antibiotic prophylaxis for more than 24 hours 6.

Targeted Prophylaxis

• A study published in 2007 found that targeted prophylaxis antibiotic administration to patients at high risk of surgical site infection can reduce the risk of SSI by 81% 7.
• The study suggested that identifying patients at risk of SSI and administering prophylaxis antibiotics to those patients can be an effective strategy in preventing SSIs after breast cancer surgery 7.

Common Causative Organisms

• The most common offending organisms responsible for SSIs in breast reconstruction surgery are methicillin-sensitive and methicillin-resistant Staphylococcus aureus 3.
• The use of first-generation cephalosporins as prophylaxis has been shown to have high resistance rates among SSI organisms 3.