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International Journal of Surgery xxx (2015) 1e7
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Antibiotic prophylaxis in prosthesis-based mammoplasty: A systematic review Q3
Naisi Huang a, Mengying Liu a, Peirong Yu b, Jiong Wu a, * a b
Department of Breast Surgery, Shanghai Cancer Center, Fudan University, No. 270, Dongan Rd., Shanghai 200032, China Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, TX 77030, United States
h i g h l i g h t s Extended systemic antibiotic prophylaxis would decrease infection risk in breast implant surgery. Topical antibiotic irrigation would decrease capsular contracture risk. Cephalosporin was the most commonly preferred antibiotic regimen. Risk factors should be taken into consideration when prescribing antibiotic prophylaxis.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 October 2014 Received in revised form 23 December 2014 Accepted 24 January 2015 Available online xxx
Introduction: Although considered as an aseptic surgery, infection after prosthesis-based mammoplasty represents the leading cause of morbidity after reconstructive and aesthetic surgery. Antibiotic prophylaxis is supported by several studies to prevent surgical site infection (SSI) and capsular contracture (CC). However, there is no high quality evidence on antibiotic prophylaxis in this area. Methods: A comprehensive literature search of Medline, Embase and CENTRAL databases was conducted for studies published through June 2014. Studies of prosthesis-based breast surgery with control group and antibiotic prophylaxis were included. Data was analyzed by meta-analysis or summarized if not qualified for meta-analysis. Results: A total of 13 studies were included. Based on random effect model, extended systemic antibiotic prophylaxis more than 24 h postoperatively could significantly decrease infection risk (pooled RR ¼ 0.638, 95%CI 0.453e0.898) compared with antibiotic prophylaxis within 24 h. In subgroup analysis, extended antibiotic prophylaxis could significantly decrease SSI risk in implant reconstruction surgery (pooled RR ¼ 0.508, 95%CI 0.349e0.739), but not in aesthetic breast surgery (pooled RR ¼ 1.458, 95%CI 0.602e3.528). Topical antibiotic irrigation could reduce CC risk (pooled RR ¼ 0.472, 95%CI 0.316e0.707), while might not be able to reduce infection risk. Cephalosporin was the most commonly preferred antibiotic regimen in included studies, which could cover the most commonly identified implantassociated bacteria. Conclusion: Extended systemic antibiotic prophylaxis should be considered to decrease SSI risk in breast implant surgery, especially in breast reconstruction. Topical antibiotic irrigation would decrease CC risk. Risk factors such as chest irradiation and diabetes should be taken into consideration when prescribing antibiotic prophylaxis. © 2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
Keywords: Antibiotics Breast Implant Infection Capsular contracture
1. Introduction Antibiotic prophylaxis in breast surgery has always been
Q1
* Corresponding author. Department of Breast Surgery, Shanghai Cancer Center, Fudan University. No. 170, Donan Rd., Shanghai, China. E-mail address: [email protected] (J. Wu).
controversial. Although CDC guidelines recommend antibiotic prophylaxis for only 24 h in clean procedures, infection rates for breast surgery are reported at between 3% and 15%, higher than the average infection rates for clean procedures [1]. Prosthesis-based breast surgery, which could be reconstructive or aesthetic, is associated with an even higher infection risk and postoperative prophylactic antibiotics are prescribed [2]. Breast implant
http://dx.doi.org/10.1016/j.ijsu.2015.01.020 1743-9191/© 2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
Please cite this article in press as: N. Huang, et al., Antibiotic prophylaxis in prosthesis-based mammoplasty: A systematic review, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.01.020
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infections involve 2%e2.5% of patients and represent the leading cause of morbidity after reconstructive and aesthetic surgery [3]. In addition to surgical site infection (SSI), capsular contracture (CC) is another commonly seen complication following implant placement. It is believed that CC remains one of the most studied and prevalent reasons for re-operative breast surgery [4]. Possible variables related to CC are biofilms, infection, hematoma, irradiation and implant characteristics [5]. Although antibiotic prophylaxis is supported by several studies to prevent SSI and CC, extended antibiotic prophylaxis could lead to systemic side effects, super-infection and development of resistant organisms. Therefore, prophylactic antibiotic protocols must be carefully investigated in an evidence-based manner. Furthermore, there is no consensus regarding antibiotic prophylaxis regimens and timing. Some researchers believed that perioperative antibiotics for 24 h were enough for prophylaxis [2], while others suggested that antibiotics should extend to 48 h postoperatively [6]. A recent review indicated that no benefit was found in patients who received more than 24 h of postoperative antibiotics, which included implant and autologous reconstruction [7]. The purpose of this systematic review was to synthesis the current evidence on both systemic and topical antibiotic prophylaxis in prosthesis-based breast surgery. By comparing postoperative complications such as SSI and CC, we verified that extended systemic antibiotic prophylaxis and topical antibiotic irrigation were beneficial for patients underwent prosthesis-based breast surgery. 2. Material and methods 2.1. Search strategy A comprehensive literature search of Medline, Embase and CENTRAL databases was conducted for studies published through June 2014. Our search criteria included English-language studies that addressed the relationship between prosthesis-based breast surgery and antibiotic prophylaxis. The key words used were: “antibiotic” or “anti-bacterial” or “anti-microbial” or “prophylaxis”; and “augmentation” or “implant” or “prosthesis” or “expander” or “mammoplasty” or “reconstruction” or “plastic surgery”; and “breast”; and “infection” or “capsular contracture”. 2.2. Study selection Two researchers (Huang and Liu) screened studies independently. On the first level, titles and abstracts were screened; on the second level, full texts were reviewed. The following inclusion and exclusion criteria were applied. Articles were included if they met the following criteria: (1) Patients who underwent breast surgery in which prosthesis were involved, including aesthetic augmentation and reconstructive mammoplasty; (2) Both prospective and retrospective studies were included; (3) Intervention group and control group had different antibiotic prophylaxis regimens including placebo and blank control. Antibiotics could be used as systemic or topical; (4) Study outcome demonstrated infection rate and/or capsule contracture rate. Articles were excluded if they met the following criteria: (1) Studies that did not involve breast prosthesis, such as breast reduction; (2) Retrospective studies that did not have a control group; (3) Antibiotics for treatment purpose but not prophylaxis purpose; (4) The number of patients who developed infection and/ or capsule contracture was not clearly stated in the study; (5) Studies that included high-risk patients only, such as patients with previous radiotherapy.
2.3. Study assessment and data extraction The methodological quality of randomized controlled trials (RCT) was assessed by Jaded scale [8], which evaluated study randomization, blinding, and the description of exclusions. Jaded scale produces scores from 0 (low quality study) to 5 (high quality study). Non-RCTs were evaluated by a nine-star system based on NewcastleeOttawa Scale (NOS), which included the selection of study groups, the comparability of groups and the ascertainment of the outcome. NOS produced scores from 0 (low quality study) to 9 (high quality study). Two authors (Huang and Liu) independently reviewed included studies. The following information was extracted from each article: first author, year of publication, study design, patient number, follow-up time, study type (reconstruction or aesthetic surgery), intervention, control and outcomes (infection rate and CC rate). Disagreements were resolved by consensus. 2.4. Data analysis Mantel-Haenszel method was used to conduct meta-analysis. Statistical significance was defined as two-tailed alpha 24 h postoperatively) could decrease infection risk compared with perioperative (
IJSU1732_proof ■ 29 January 2015 ■ 1/7
International Journal of Surgery xxx (2015) 1e7
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Antibiotic prophylaxis in prosthesis-based mammoplasty: A systematic review Q3
Naisi Huang a, Mengying Liu a, Peirong Yu b, Jiong Wu a, * a b
Department of Breast Surgery, Shanghai Cancer Center, Fudan University, No. 270, Dongan Rd., Shanghai 200032, China Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, TX 77030, United States
h i g h l i g h t s Extended systemic antibiotic prophylaxis would decrease infection risk in breast implant surgery. Topical antibiotic irrigation would decrease capsular contracture risk. Cephalosporin was the most commonly preferred antibiotic regimen. Risk factors should be taken into consideration when prescribing antibiotic prophylaxis.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 October 2014 Received in revised form 23 December 2014 Accepted 24 January 2015 Available online xxx
Introduction: Although considered as an aseptic surgery, infection after prosthesis-based mammoplasty represents the leading cause of morbidity after reconstructive and aesthetic surgery. Antibiotic prophylaxis is supported by several studies to prevent surgical site infection (SSI) and capsular contracture (CC). However, there is no high quality evidence on antibiotic prophylaxis in this area. Methods: A comprehensive literature search of Medline, Embase and CENTRAL databases was conducted for studies published through June 2014. Studies of prosthesis-based breast surgery with control group and antibiotic prophylaxis were included. Data was analyzed by meta-analysis or summarized if not qualified for meta-analysis. Results: A total of 13 studies were included. Based on random effect model, extended systemic antibiotic prophylaxis more than 24 h postoperatively could significantly decrease infection risk (pooled RR ¼ 0.638, 95%CI 0.453e0.898) compared with antibiotic prophylaxis within 24 h. In subgroup analysis, extended antibiotic prophylaxis could significantly decrease SSI risk in implant reconstruction surgery (pooled RR ¼ 0.508, 95%CI 0.349e0.739), but not in aesthetic breast surgery (pooled RR ¼ 1.458, 95%CI 0.602e3.528). Topical antibiotic irrigation could reduce CC risk (pooled RR ¼ 0.472, 95%CI 0.316e0.707), while might not be able to reduce infection risk. Cephalosporin was the most commonly preferred antibiotic regimen in included studies, which could cover the most commonly identified implantassociated bacteria. Conclusion: Extended systemic antibiotic prophylaxis should be considered to decrease SSI risk in breast implant surgery, especially in breast reconstruction. Topical antibiotic irrigation would decrease CC risk. Risk factors such as chest irradiation and diabetes should be taken into consideration when prescribing antibiotic prophylaxis. © 2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
Keywords: Antibiotics Breast Implant Infection Capsular contracture
1. Introduction Antibiotic prophylaxis in breast surgery has always been
Q1
* Corresponding author. Department of Breast Surgery, Shanghai Cancer Center, Fudan University. No. 170, Donan Rd., Shanghai, China. E-mail address: [email protected] (J. Wu).
controversial. Although CDC guidelines recommend antibiotic prophylaxis for only 24 h in clean procedures, infection rates for breast surgery are reported at between 3% and 15%, higher than the average infection rates for clean procedures [1]. Prosthesis-based breast surgery, which could be reconstructive or aesthetic, is associated with an even higher infection risk and postoperative prophylactic antibiotics are prescribed [2]. Breast implant
http://dx.doi.org/10.1016/j.ijsu.2015.01.020 1743-9191/© 2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
Please cite this article in press as: N. Huang, et al., Antibiotic prophylaxis in prosthesis-based mammoplasty: A systematic review, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.01.020
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infections involve 2%e2.5% of patients and represent the leading cause of morbidity after reconstructive and aesthetic surgery [3]. In addition to surgical site infection (SSI), capsular contracture (CC) is another commonly seen complication following implant placement. It is believed that CC remains one of the most studied and prevalent reasons for re-operative breast surgery [4]. Possible variables related to CC are biofilms, infection, hematoma, irradiation and implant characteristics [5]. Although antibiotic prophylaxis is supported by several studies to prevent SSI and CC, extended antibiotic prophylaxis could lead to systemic side effects, super-infection and development of resistant organisms. Therefore, prophylactic antibiotic protocols must be carefully investigated in an evidence-based manner. Furthermore, there is no consensus regarding antibiotic prophylaxis regimens and timing. Some researchers believed that perioperative antibiotics for 24 h were enough for prophylaxis [2], while others suggested that antibiotics should extend to 48 h postoperatively [6]. A recent review indicated that no benefit was found in patients who received more than 24 h of postoperative antibiotics, which included implant and autologous reconstruction [7]. The purpose of this systematic review was to synthesis the current evidence on both systemic and topical antibiotic prophylaxis in prosthesis-based breast surgery. By comparing postoperative complications such as SSI and CC, we verified that extended systemic antibiotic prophylaxis and topical antibiotic irrigation were beneficial for patients underwent prosthesis-based breast surgery. 2. Material and methods 2.1. Search strategy A comprehensive literature search of Medline, Embase and CENTRAL databases was conducted for studies published through June 2014. Our search criteria included English-language studies that addressed the relationship between prosthesis-based breast surgery and antibiotic prophylaxis. The key words used were: “antibiotic” or “anti-bacterial” or “anti-microbial” or “prophylaxis”; and “augmentation” or “implant” or “prosthesis” or “expander” or “mammoplasty” or “reconstruction” or “plastic surgery”; and “breast”; and “infection” or “capsular contracture”. 2.2. Study selection Two researchers (Huang and Liu) screened studies independently. On the first level, titles and abstracts were screened; on the second level, full texts were reviewed. The following inclusion and exclusion criteria were applied. Articles were included if they met the following criteria: (1) Patients who underwent breast surgery in which prosthesis were involved, including aesthetic augmentation and reconstructive mammoplasty; (2) Both prospective and retrospective studies were included; (3) Intervention group and control group had different antibiotic prophylaxis regimens including placebo and blank control. Antibiotics could be used as systemic or topical; (4) Study outcome demonstrated infection rate and/or capsule contracture rate. Articles were excluded if they met the following criteria: (1) Studies that did not involve breast prosthesis, such as breast reduction; (2) Retrospective studies that did not have a control group; (3) Antibiotics for treatment purpose but not prophylaxis purpose; (4) The number of patients who developed infection and/ or capsule contracture was not clearly stated in the study; (5) Studies that included high-risk patients only, such as patients with previous radiotherapy.
2.3. Study assessment and data extraction The methodological quality of randomized controlled trials (RCT) was assessed by Jaded scale [8], which evaluated study randomization, blinding, and the description of exclusions. Jaded scale produces scores from 0 (low quality study) to 5 (high quality study). Non-RCTs were evaluated by a nine-star system based on NewcastleeOttawa Scale (NOS), which included the selection of study groups, the comparability of groups and the ascertainment of the outcome. NOS produced scores from 0 (low quality study) to 9 (high quality study). Two authors (Huang and Liu) independently reviewed included studies. The following information was extracted from each article: first author, year of publication, study design, patient number, follow-up time, study type (reconstruction or aesthetic surgery), intervention, control and outcomes (infection rate and CC rate). Disagreements were resolved by consensus. 2.4. Data analysis Mantel-Haenszel method was used to conduct meta-analysis. Statistical significance was defined as two-tailed alpha 24 h postoperatively) could decrease infection risk compared with perioperative (
