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ANTIBIOTIC SELECTION IN THE TREATMENT OF INFECTIOUS COMPLICATIONS OF IMPLANT BASED BREAST RECONSTRUCTION
Katie Weichman, MD, Steve Levine, MD, Stelios Wilson, BS, Jamie Levine, MD, Nolan Karp, MD.
New York University, New York, NY, USA.
Background: Infection requiring explantation remains the most dreaded and devastating complication associated with implant-based breast reconstruction. There are many treatment algorithms to prevent reconstructive failure in the face of infection utilizing both oral and intravenous antibiotics. In the absence of patient specific culture data, antibiotic selection is generally directed towards broad-spectrum coverage based on historical data. We hypothesize that reviewing our institutions microbiology data obtained from explanted implant-based breast reconstructions would provide a rational basis for antibiotic selection in the future.
Methods: A retrospective review of 747 consecutive immediate implant based breast reconstructions at a single institution from November 2007 to November 2010 was conducted. Implants requiring explantation were identified and patient demographics, implant characteristics, presence of skin necrosis, microbiological data, and outcomes were reviewed for analysis.
Results: Fifty (6.7%) implants requiring explantation were identified. Eleven permanent round smooth silicone implants and thirty-nine round textured tissue expanders were explanted with average size 637mL and 430mL respectively. Twenty-eight implants were explanted due to infection, eleven due to exposure from skin necrosis, six due to combination of flap necrosis and infection, one secondary to cancer invasion into the skin, and four for symmetry. Reconstruction was salvaged in twenty-eight breasts (56.0%); thirteen implant reconstruction were salvaged; five patients pedicled latissimus dorsi flap and ten breast went on to microvascular free flap reconstruction. Nineteen explants had microbiology data available. The most common organism isolated was staphylococcus epiderminis (6), followed by serratia marcescens (4), staphylococcus aureus (4), pseudomonas aeruginosa (3), enterococcus (1), and ecoli (1). 94% of these cultures were sensitive to oral fluoroquinolones and 47% were resistant to first generation cephalosporins.
Conclusions: Infections associated with implant-based breast reconstructions continues to threaten explantation and reconstructive failure. Based on our microbiologic data, initial cellulitis amenable to oral antibiotics should be treated with oral fluoroquinolones as a first line treatment. If this regiment fails, intravenous Cefepime and Vancomycin should be initiated. Obviously, clinical judgment regarding specific patient risk factors and compliance plays a role in decision-making, but this data provides an evidence-based rational for first line oral antibiotic selection.
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