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Perioperative Antibiotic Prophylaxis and Surgical Site Infections in implant-based Breast Reconstruction
Natalia Mejia
*, Aryan Gupta, Maxim Narduzzi, Alexander Chang, Adam Walchak, Sameer A. Patel
Division of Plastic and Reconstructive Surgery, LKSOM Temple University Hospital/Fox Chase Cancer Center, Fox Chase Cancer Center, Philadelphia, PA
B
ackground: Surgical site infections (SSIs) significantly impact morbidity and reconstructive outcomes following implant-based breast reconstruction after mastectomy. Cefazolin is the standard prophylactic agent, yet penicillin allergy labels, despite low rates of severe hypersensitivity, frequently prompt substitution with alternative antibiotics. This study assessed the relationship between antibiotic selection and SSI rates, with attention to penicillin allergy status and infection microbiology.
Methods: A single-center retrospective review was performed of adults undergoing implant-based breast reconstruction between July 2016 and December 2025. Penicillin allergy status, perioperative prophylaxis, SSI occurrence, and wound culture data were collected. SSI rates were compared between patients receiving cefazolin and those receiving alternative agents.
Results: Among 614 patients (923 procedures), 94 (15.3%) carried a penicillin allergy label; 6 (1.0%) reported anaphylaxis, 3 (0.5%) had drug-induced hepatotoxicity, and 85 (13.8%) reported nonanaphylactic or undocumented reactions. SSI rates were significantly higher with alternative prophylaxis compared with cefazolin (8.8% vs 3.8%, P=0.023). No anaphylactic reactions to prophylaxis occurred. Among 12 culture-positive SSIs, the most frequently isolated organisms were Pseudomonas aeruginosa (3/12, 25.0%) and methicillin-sensitive Staphylococcus aureus (2/12, 16.7%). Three patients (25.0%) were penicillin-allergic and had received clindamycin, with P. aeruginosa isolated in 2 of 3 cases (66.7%). Gram-negative organisms accounted for 5 of 12 infections (41.7%), including P. aeruginosa and Proteus mirabilis.
Conclusion: Alternative prophylaxis was associated with higher SSI rates. Culture data suggest coverage gaps, particularly clindamycin's lack of gram-negative activity, may contribute to infections in penicillin-allergic patients. First-generation cephalosporins should remain standard, with alternatives reserved for documented severe hypersensitivity.
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