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The Breast (2007) 16, 68–72

THE BREAST

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ORIGINAL ARTICLE

Current use of antibiotic prophylaxis in breastsurgery: A nationwide survey

Darren Ng�, Prateesh M. Trivedi, Anup K. Sharma, Dibyesh Banerjee

Breast and Endocrine Unit, St. George’s Hospital, Blackshaw Road, London SW17 0QT, UK

Received 3 April 2006; received in revised form 3 June 2006; accepted 20 June 2006

KEYWORDSSurgical site infec-tion;Breast surgery;Antibiotic prophy-laxis

ee front matter & 2006reast.2006.06.004

ing author. Tel.: +44 7741300.ess: darren76@hotmail.

Summary There is currently no consensus regarding the use of antibioticprophylaxis in breast surgery. This postal survey aimed to establish the currentpractice in perioperative antibiotic use for breast surgery in the United Kingdom.Questionnaires were sent to 406 breast surgeons, enquiring about antibiotic use forcommon breast procedures. A total of 266 completed questionnaires were returned(65.5%). Over 80% of surgeons who performed breast augmentations, myocutaneousflap reconstructions and implant reconstructions used antibiotic prophylaxis. Up to33% used antibiotic prophylaxis for wide local excisions (WLEs), mastectomies andaxillary surgery for breast cancer, while 62% and 45% used antibiotics for breastreductions and duct excisions, respectively. The most common antibiotic used wasco-amoxiclav. The variation in practice regarding antibiotic prophylaxis in breastsurgery reflects the lack of reliable evidence for its efficacy. Further randomisedcontrolled trials are required, taking into consideration specific risk factors affectingpostoperative infection rate for breast surgery.& 2006 Elsevier Ltd. All rights reserved.

Introduction

Surgical site infection (SSI) is a significant cause ofmorbidity and mortality. In the context of breastsurgery, this can lead to significant psychologicaltrauma and delay in receiving adjuvant chemother-apy or radiotherapy. SSI rates in breast surgery havebeen reported to be between 1.4% and 2.3% for

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7612818;

com (D. Ng).

excision biopsies;1–3 between 6.6% and 18% forbreast conserving surgery1,3 and between 19% and38.3% for mastectomies.1,3 SSI rates for aestheticbreast surgery have been reported to be between1% and 7%.4–6

The role of antibiotic prophylaxis in the reduc-tion of post-operative infection rate is wellestablished in clean-contaminated procedures.7

However, much controversy still surrounds the useof antibiotics for clean procedures such as electivebreast surgery, as injudicious use can lead todevelopment of microbial resistance, increased

d.

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Current use of antibiotic prophylaxis in breast surgery 69

number of adverse reactions to antibiotics, un-necessary medical costs and also increased con-sumption of nursing staff resources in drugadministration.

There is currently no consensus regarding the useof antibiotic prophylaxis in breast surgery, anddisparate practices exist even amongst surgeonswithin the same department. This postal surveyaimed to establish the current practice of perio-perative antibiotic usage in breast surgery in theUnited Kingdom.

Methods

A postal survey of practising consultant surgeonswith an interest in breast surgery was performedbetween June and August 2005. The names of thesurgeons (full members of the Association of BreastSurgery) were obtained from the British Associationof Surgical Oncology (BASO) Membership Directory2005. The questionnaire sent out listed a number ofcommon breast procedures performed and whetheror not antibiotic prophylaxis was used. Further-more, the type of antibiotic utilised was alsoincluded. The scope of the questionnaire is shownin Fig. 1. The reply envelopes were numbered inorder to facilitate a second questionnaire to besent out to those who had not responded within

Type of breast surgery

Averagperfo

y

Breast Reduction _

Breast Augmentation _

Wide Local Excision of Breast Cancer (No Wire) _

Wide Local Excision of Breast Cancer (Wire Localisation) _

Mastectomy (No Nodes) _

Mastectomy + Axillary Node Clearance _

Axillary Node Sampling / ClearanceOnly _

Sentinel Lymph Node Biopsy _

Myocutaneous Flap Reconstruction _

Implant Reconstruction _

Total Duct Excision / Microdochotomy _

Minor Procedures (excision biopsies,benign breast lumps,mamillary fistula, correction of nipple inversion etc) _

Figure 1 A sample of the questionn

a month. Once the reply envelopes had beenreceived, the completed questionnaires wereseparated from the envelopes to anonymise thedata.

Results

There were 420 surgeons listed as full members ofthe Association of Breast Surgery at BASO in thedirectory. The departmental database providedthree more names of surgeons not listed in thedirectory. Therefore, a total of 423 questionnaireswere sent out. The number of returned question-naires was 288 (68.1%). There were 22 uncom-pleted questionnaires, 17 of which were fromsurgeons who have retired or left the unit, wereon long term leave, or have stopped performingbreast surgery. The remaining five were fromsurgeons who declined to participate and hencewere regarded as non-responders. The resultingtotal number of practising breast surgeons listed inthe directory who were sent questionnaires was406. The number of completed questionnaires was266 (65.5%).

The percentages of surgeons performing thevarious procedures are shown in Fig. 2. The vastmajority of surgeons perform the core breastcancer procedures of wide local excisions (WLEs),

e numberrmed perear

Antibiotic use?(Please circle)

Drug(Please circle)

Indicate ifother

A = AugmentinC = Cephalo sporin

O = Other

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____ Yes No A C O

____Yes No A C O

aire used for the postal survey.

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Figure 2 Percentages of surgeons who perform the various procedures: Breast augment: Breast augmentation; WLE:Wide local excision; Wire WLE: Wire-localisation wide local excision; ANC: Axillary node clearance; ANS: Axillary nodesampling; SNB: Sentinel lymph node biopsy; Myocut flap recon: Myocutaneous flap reconstruction; Implant recon:Implant reconstruction; TDE: Total duct excision.

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Figure 3 Percentages of surgeons using antibiotic prophylaxis for the various procedures.

D. Ng et al.70

mastectomies, axillary surgery and minor proce-dures. The number of surgeons performing breastreconstructive surgery is approaching 50%.

The percentages of surgeons who use antibioticprophylaxis for the various procedures are shown inFig. 3. The majority (over 80%) of surgeonsperforming breast augmentations or reconstructionwork use antibiotics. Up to 33% use antibioticswhen performing WLEs, mastectomies and axillarysurgery.

The type of antibiotic chosen for prophylaxis canbe seen in Fig. 4. The majority of surgeons favour

the use of co-amoxiclav. The numbers usingcephalosporins or ‘‘other’’ antibiotics are similar.‘‘Other’’ antibiotics included benzylpenicillin, flu-cloxacillin and gentamicin.

Discussion

In this survey, the majority (over 80%) of breastsurgeons who perform breast augmentations, myo-cutaneous flap and implant reconstructions useprophylactic antibiotics. Interestingly, only 43% of

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10%

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60%

70%

80%

90%

100%

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reco

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Implan

t reco

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TDE/micr

odochec

tom

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Minor pro

cedure

s

Other

Cephalosporin

Co-amoxiclav

Figure 4 Distribution of the choice of antibiotics amongst surgeons who use antibiotic prophylaxis for each procedure.

Current use of antibiotic prophylaxis in breast surgery 71

plastic surgeons who responded to a 1975 surveyconducted in the United States of America usedprophylactic antibiotics for breast augmentation.6

Up to 33% of surgeons who perform WLEs, mastec-tomies and lymph node surgery for breast canceruse prophylactic antibiotics in our survey, despitethe lack of level I or II evidence supporting thispractice. For breast reductions and duct excisions,there appears to be a fairly equal split betweensurgeons who use antibiotic prophylaxis and thosewho do not.

Although numerous studies have been conductedin the past to justify the use of antibioticprophylaxis in breast surgery, the findings havebeen conflicting. Several authors have reported asignificant reduction in postoperative infection rateusing antibiotics including cefotaxime and azithro-mycin (38–88% reduction).8–10 Conversely otherauthors including Penel et al.11 Gupta et al.12 andWagman et al.13 did not find any significantreduction in postoperative infection rate withantibiotic prophylaxis.

The antibiotic most commonly used in our surveywas co-amoxiclav followed by a cephalosporin.However, most studies in the literature have lookedat the efficacy of cephalosporins in reducing post-operative infections in breast surgery,7,8,11,14,15

albeit with mixed results. Gupta et al.12 used co-amoxiclav in their study and found that it did notsignificantly reduce postoperative infection ratesafter clean elective breast surgery. Nevertheless,the pathogens most frequently implicated in post-operative breast infections have been found to be

Staphylococci1,16 which are usually sensitive to co-amoxiclav.

Some of the responding surgeons who did notroutinely use prophylactic antibiotics for breastsurgery added that they would do so only for re-operations. In fact, there is good evidence thatthere is an increased risk of SSI with re-operationsfor breast cancer. Chen et al.16 showed a 6.4%infection rate for a one-step operation vs. 11.1% fora two-step operation between 1970–1976, andsubsequently 2.6% for one-step operation vs. 7.6%for two-step operations between 1980–1986. In twoseparate studies, it was found that the mastectomywound infection rate varied with the method ofbiopsy. Lipshy et al.17 found that the post-mastect-omy infection rate was 1.6% when fine needleaspiration (FNA) was used, compared with 6.9%with open biopsy. Beatty et al.18 reported aninfection rate of 3.2% with FNA, and 9.5% withopen biopsy. Tran et al.19 reported a statisticallysignificant difference (1.6% vs. 9.4%) in the in-cidence of wound infection comparing the initialprocedure vs. the subsequent operation, and alsoshowed that the nature of the initial operationaffected the infection rate after re-operation, withoperative biopsy resulting in a higher subsequentinfection rate compared with core biopsy. Tran etal.19 also mentioned a further increase in infectionrate after re-operation if the initial operationinvolved lymph node dissection, whereas wirelocalisation did not increase postoperative infec-tion rate. However, looking at the results of oursurvey, axillary surgery did not seem to significantly

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D. Ng et al.72

influence prophylactic antibiotic usage, whereaswire WLE seemed to have resulted in twice thenumber of surgeons using antibiotic prophylaxiscompared to WLE alone.

Other specific factors which have been found toincrease the rate of postoperative infection inbreast surgery aside from re-operation are asfollows: obesity, concomitant chemotherapy andradiation, radical surgery, insertion of a seconddrain during the late postoperative period, drainduration more or equal to 19 days,1 closed suctiondrainage, location of drain, prolonged preoperativestay, length of surgery, greater mean age,3 andsmoking.20 All of these need to be considered andadjusted for in the design of future randomisedcontrolled trials. Until further trials have takenplace, it would currently seem reasonable tosuggest the use of prophylactic co-amoxiclav onlyfor operations involving implants, for re-opera-tions, for duct excisions for recurrent infectionsand if there are adverse patient factors as men-tioned above.

Conclusion

The heterogeneity of any practice in evidence-based medicine reflects to a certain extent thereliability of available evidence for or against thepractice. The findings of this survey on current useof antibiotic prophylaxis in breast surgery not onlyreflects the lack of convincing evidence available inthis area of interest, but also serves to form a basisfor future comparison to examine how practicechanges when more randomised controlled trialshave been conducted to confirm whether or notantibiotic prophylaxis in breast surgery is costeffective as well as resulting in reduced morbidity.

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