Exploring Infectious Complications following Breast Reconstruction Tissue Expander Placement in Penicillin-allergic Patients

Abstract

INTRODUCTION: In an effort to avoid anaphylaxis, penicillin-allergic patients are often given vancomycin or clindamycin as alternative perioperative antibiotics.1 In implant-based breast reconstruction patients, many of whom are at heightened risk for surgical site infections, it is prudent to evaluate the complication profile of those receiving alternative antibiotic coverage. Without additional risk factors for infection following breast reconstruction, the risk of infection is below 5%.2 However, seldom do studies consider patient allergies to penicillin a risk factor. When given via the intravenous route, it takes clindamycin 45 minutes to reach peak serum concentrations whereas it takes cefazolin 15 minutes to reach peak serum concentration.3,4 We hypothesize that patients who experience penicillin allergies experience increased infection rates with different speciation compared to their penicillin nonallergic counterparts because current recommendations do not facilitate sufficient time for the prophylactic antibiotic to reach peak concentration and efficacy. METHODS: This was a retrospective review of consecutive patients who underwent breast reconstruction with tissue expander placement between 1/1/2010 and 12/31/2018. Demographic data was collected, and the primary outcome of this study was development of infection. Infection-related complications were defined as those infections requiring re-admission for intravenous antibiotics or reoperation. Type of infection, culture speciation, treatment regimen, and time between operation and onset of infection were recorded. Other implant-based complications were recorded and analyzed including seroma, hematoma, wound dehiscence, mastectomy flap necrosis, capsular contracture, implant malposition, implant rupture, fat necrosis, premature tissue expander or implant explantation, and flap donor or recipient site morbidity. RESULTS: One-hundred fifty-three (153) patients were included in the review. Thirty-five (35) had a penicillin allergy and received alternative perioperative antibiotic coverage. Infection-related complications occurred in 45.7% of penicillin-allergic patients and 28.0% of those without penicillin allergies (p=0.048). Premature explantation of a tissue expander was performed in 25.7% of penicillin-allergic patients and 11.9% of controls (p=0.0441). CONCLUSIONS: In this population, penicillin-allergic patients experience significantly higher rates of infection-related complications than patients without penicillin allergies. This may be due to decreased effectiveness of alternative regimens due to dose timing or the community specific antibiogram. This suggests inadequate antibiotic coverage by the alternative antibiotics most commonly used. There is a need for further reform of perioperative antibacterial guidelines to optimize outcomes in this patient population, whose oncologic therapy increases their infection risk from the outset of reconstruction. REFERENCES: 1. Ranganathan K, Sears ED, Zhong L, et al. Antibiotic Prophylaxis after Immediate Breast Reconstruction: The Reality of Its Efficacy. Plast Reconstr Surg. 2018;141(4):865-877. doi:10.1097/PRS.0000000000004204 2. Baghaki S, Soybir GR, Soran A. Guideline for Antimicrobial Prophylaxis in Breast Surgery. J Breast Health. 2014;10(2):79-82. doi:10.5152/tjbh.2014.1959 3. Leigh DA. Antibacterial activity and pharmacokinetics of clindamycin. J Antimicrob Chemother. 1981;7(suppl A):3-9. doi:10.1093/jac/7.suppl_A.3 4. White RR, Pitzer KD, Fader RC, Rajab MH, Song J. Pharmacokinetics of Topical and Intravenous Cefazolin in Patients with Clean Surgical Wounds: Plast Reconstr Surg. 2008;122(6):1773-1779. doi:10.1097/PRS.0b013e31818d5899