Weichman Katie E, Levine Steve M, Wilson Stelios C, Choi Mihye, Karp Nolan S
Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, NY 10016, USA.
Ann Plast Surg. 2013 Aug;71(2):140-3. doi: 10.1097/SAP.0b013e3182590924.
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.
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.
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.
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.
需要取出植入物的感染仍然是基于植入物的乳房重建最具破坏性的并发症。面对感染，有许多治疗方案可用于预防重建失败，包括口服和静脉使用抗生素。在缺乏患者特异性培养数据的情况下，抗生素选择通常基于历史数据针对广谱覆盖。我们假设回顾我们机构从基于植入物的乳房重建取出物中获得的微生物学数据将为未来抗生素选择提供合理依据。
对2007年11月至2011年5月在单一机构进行的902例连续即刻基于植入物的乳房重建进行回顾性研究。确定需要通过介入放射学取出植入物或进行引流的植入物重建。回顾患者人口统计学、植入物特征、皮肤坏死情况、微生物学数据和结果。
43例（4.76%）需要通过介入放射学取出植入物或进行引流的植入物重建符合本研究纳入标准。5例患者（11.6%）植入圆形、光滑硅胶植入物，36例（88.4%）植入带纹理的组织扩张器。26枚植入物因感染被取出；3枚因皮肤坏死暴露；11枚因皮瓣坏死和感染合并；1枚其次是因为癌症侵犯皮肤。21例乳房（51.2%）重建成功：12例（57.1%）通过植入物重建，5例（23.8%）通过带蒂背阔肌皮瓣，4例（19.1%）通过游离微血管皮瓣。30例取出物有微生物学数据。分离出的最常见微生物是表皮葡萄球菌（10例），其次是对甲氧西林敏感的金黄色葡萄球菌（5例）、粘质沙雷菌（5例）、铜绿假单胞菌（4例）、肠球菌（3例）、大肠杆菌（2例）、阴沟肠杆菌（2例）、B组链球菌（1例）和摩根摩根菌（1例）。40%的微生物对头孢唑林耐药；然而，86%对庆大霉素敏感，80%对左氧氟沙星敏感，63%对环丙沙星敏感。
与基于植入物的乳房重建相关的感染继续威胁植入物取出和重建失败。基于我们的微生物学数据，适合口服抗生素治疗的初始蜂窝织炎应以口服氟喹诺酮类药物作为一线治疗。如果该方案失败，应开始静脉使用亚胺培南或庆大霉素和万古霉素。显然，关于特定患者风险因素和依从性的临床判断应在决策中发挥作用，但这些数据为一线口服抗生素选择提供了循证依据。
