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Rampino Cordaro et al. Breast reconstruction, antibiotics and drains

contamination of the wound. [15,18,19] Hence, although many as 61% until drain removal. Although this behavior
the drain performs an indispensable function, namely is not very judicious, it is understandable. Indeed,
to eliminate accumulated serum from the wound site should a surgery patient fall prey to an SSI, there are
and thereby deprive endogenous pathogens of an many legal questions to consider, not to mention the
excellent medium for proliferation, it can provide a clinical and financial consequences of their sequelae,
route through which such pathogens can enter the which may include implant loss, delay in neo-adjuvant
body. [20-24] therapy, unsatisfactory or unsightly outcomes, and, as
a consequence, prolonged hospital stays and even
As mentioned previously, the regional guidelines revision surgery. This represents a strong incentive for
for antibiotic prophylaxis (AP) dictate the use of 2 g surgeons to administer postoperative AP, especially
cephazolin (plus 1 g in operations lasting longer than in patients with drains, in the hope that prolonging
3.5 h) solely before surgery. Cephazolin, the first choice the course of AP will reduce the risk of SSI. The
antibiotic, is a cephalosporin that protects against a practice is even more common in immediate prosthetic
wide range of both gram-positive (staphylococcus reconstruction patients, with the fear of infection-
strains, including aureus; coagulase-negative related implant loss being the driving concern. [27,28]
staphylococci, with the exception of methycillin-
resistant strains; beta-haemolitic streptococcus However, the unrestrained use of antibiotics, perhaps
groups A and B) and gram-negative (E. coli and fueled by the lack of prospective studies in the
Klebsiella) bacteria. Cephalosporins are generally literature, has led to the development of methicillin-
well-tolerated and inexpensive drugs with time- resistant colonies of Staphylococcus epidermidis, and
dependent pharmacokinetics and a half-life of roughly to an increase in the incidence of colitis secondary
2 h. They are considered high protein bonding (85%), to Clostridium difficilis, in addition to side effects
and provide excellent tissue distribution. Cephazolin, and secondary infections. Furthermore, antibiotics
in particular, is one of the preferred options for clean administered after wound closure seem to have no
surgery. prophylactic effect on bacterial contamination during
the surgery itself. [29,30]
In cases of cephalosporin allergy, vancomycin or
clindamycin are other viable options. Other drugs, Having administered short-term AP as per the
such as ampicillin, amoxicillin, piperacillin, ampicillin/ recommended guidelines, 2 (2.5%) out of the 80 patients
sulbactam, and amoxicillin/clavulanic acid, are also drain secretion samples analyzed were found to be
widely used for surgical applications, and are very positive for microbial strains, specifically Pseudomonas
efficacious against enterococcus strains, albeit no aeruginosa in 1 case and Propionibacterium acnes
more so than the cephalosporins in AP. in the other. The patient whose drain was found to
be positive for Pseudomonas aeruginosa developed
The study charts showed that all 86 were administered progressive loss of the apical portion of the skin paddle,
2 g of cephazolin intravenously, 30 min before skin originating at the medial apex, and consequent implant
incision, with an additional 1 g in cases lasting longer exposure in the postoperative period. This makes
than 3.5 h. With this treatment, as already stated, 3 it likely that the route of the bacterial contamination
out of the 86 showed contaminated drainage secretion was, in fact, the exposed implant. In contrast, the
and 1 peri prosthetic infection but sterile drain. patient whose drainage secretion tested positive for
Propionibacterium acnes developed no clinical signs
The study charts confirmed adherence to the duration of infection, and completed the weekly expansion cycle
of AP suggested by both the literature and regional with no complications.
guidelines. Indeed, there is no statistical proof that long-
term AP (for example until the time of drain removal) In a further patient, a positive result for Staphylococcus
is any more efficacious at preventing SSIs. On the aureus was detected in a peri-prosthetic accumulation
[4]
contrary, there are various reports that extending AP to formed in the post-operative period, but the fluid taken
cover tubes, drains and catheters is either useless [1,2,8] from the drain of the same patient was found to be
or inadvisable. [25,26] negative.

Despite this evidence, it has been reported that many As contaminated drainage samples were found in only
hospitals, both in Italy and abroad, routinely use long- 2 out of the 86 patients, one conceivably attributable
term AP in surgical cases. Perrotti et al., for example, to implant exposure, this study appears to confirm
[6]
state that over 50% of the plastic surgeons interviewed the validity of the current guidelines regarding short-
administer AP well beyond the operating time, and as term AP. Nevertheless, there are certain limitations
Plastic and Aesthetic Research ¦ Volume 4 ¦ February 28, 2017 29