title: Antibiotic selection for the treatment of infectious complications of implant-based breast reconstruction.
abstract: BACKGROUND
  Infection requiring explantation remains the most devastating complication associated with implant-based breast reconstruction. There are many treatment algorithms to prevent reconstructive failure in face of infection using both oral and intravenous antibiotics. In the absence of patient-specific culture data, antibiotic selection is generally directed toward broad-spectrum coverage based on historical data. We hypothesize that reviewing our institution's 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 902 consecutive immediate implant-based breast reconstructions at a single institution from November 2007 to May 2011 was conducted. Implant reconstructions requiring explantation or drainage by interventional radiology were identified. Patient demographics, implant characteristics, presence of skin necrosis, microbiological data, and outcomes were reviewed.
  
  
  RESULTS
  Forty-three (4.76%) implant reconstructions requiring explantation or drainage by interventional radiology met the inclusion criteria for this study. Five patients (11.6%) had round, smooth silicone implants, and 36 (88.4%) had textured tissue expanders. Twenty-six implants were explanted because of infection; 3, because of exposure from skin necrosis; and 11, because of the combination of flap necrosis and infection; and 1, secondarily because of cancer invasion into the skin. Reconstruction was salvaged in 21 breasts (51.2%): 12 (57.1%) by implant reconstruction, 5 (23.8%) by pedicled latissimus dorsi flaps, and 4 (19.1%) with a microvascular free flap. Thirty explants had microbiology data available. The most common organism isolated was Staphylococcus epidermidis (10), followed by methicillin-sensitive Staphylococcus aureus (5), Serratia marcescens (5), Pseudomonas aeruginosa (4), enterococcus (3), Escherichia coli (2), Enterobacter (2), group B streptococcus (1), and Morganella morganii (1). Forty percent of the organisms were resistant to cefazolin; however, 86% were sensitive to gentamicin, 80% were sensitive to Levaquin, and 63% were sensitive to ciprofloxacin.
  
  
  CONCLUSIONS
  Infection associated with implant-based breast reconstructions continues to threaten explantation and reconstructive failure. Based on our microbiological data, initial cellulitis amenable to oral antibiotics should be treated with oral fluoroquinolones as a first-line treatment. If this regimen fails, intravenous imipenem or gentamicin and vancomycin should be initiated. Obviously, clinical judgment regarding specific patient risk factors and compliance should play a role in decision making, but these data provide an evidence-based rationale for first-line oral antibiotic selection.
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, NY 10016, USA. weichmank@gmail.com
authors.forename: Katie E
authors.initials: KE
authors.lastname: Weichman
authors.forename: Steve M
authors.initials: SM
authors.lastname: Levine
authors.forename: Stelios C
authors.initials: SC
authors.lastname: Wilson
authors.forename: Mihye
authors.initials: M
authors.lastname: Choi
authors.forename: Nolan S
authors.initials: NS
authors.lastname: Karp
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019928:Breast Implantation; D018427:Breast Implants; D020878:Device Removal; D004322:Drainage; D024881:Drug Resistance, Bacterial; D005260:Female; D024841:Fluoroquinolones / Q000627:therapeutic use; D058752:Free Tissue Flaps / Q000637:transplantation; D005839:Gentamicins / Q000627:therapeutic use; D016905:Gram-Negative Bacterial Infections / Q000188:drug therapy* / Q000382:microbiology / Q000601:surgery; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy* / Q000382:microbiology / Q000601:surgery; D006801:Humans; D015378:Imipenem / Q000627:therapeutic use; D007275:Injections, Intravenous; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D015641:Radiography, Interventional; D012086:Reoperation; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000188:drug therapy* / Q000382:microbiology / Q000601:surgery; D015625:Tissue Expansion Devices; D016896:Treatment Outcome; D014640:Vancomycin / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D024841:Fluoroquinolones; D005839:Gentamicins; D014640:Vancomycin; D015378:Imipenem