Data from 2020 indicate that unilateral and bilateral mastectomies were performed in about 18.1% and 11.3%, respectively, of patients with early BC. In 2022, the American Society of Plastic Surgery reported that 78% of reconstructive surgeries were implant-based, whereas the rest were autologous tissue reconstructions using diverse donor tissue sites.

Regarding implant-based reconstructions, they can be performed single-staged at the time of mastectomy with immediate permanent implant placement, or they can be done in a two-stage process that involves the use of breast tissue expander matrix followed by exchange with a permanent implant, usually within 6 months of the initial surgery. This latter procedure allows for appropriate breast volume to be achieved and for the BC survivor to recover from adjuvant radiation and chemotherapy.

One of the major complications of breast reconstructive surgery is infection, which can occur in 2.5% to 24% of patients; 70% of these infections occur within the first 90 days following surgery. To help address this concern, a recent review discussed prevention, diagnosis, and treatment and offered some pearls of wisdom regarding reconstructive breast implant–related infections.

Risk factors associated with reconstructive breast implant–related infections include increased BMI; tobacco use; disruption of the lymphovascular system; receiving adjuvant chemotherapy; use of acellular dermal matrices (ADM) employed to help repair and regenerate tissue; and prolonged surgical draining placement. Recently, data from a multivariable analysis of a retrospective cohort study conducted in the perioperative setting among BC patients undergoing immediate direct breast implantation found an association between the use of cannabis and an increased rate of complications, including higher rates of cellulitis requiring treatment with IV antibiotics; an increased need to return to the operating room within 90 days of reconstructive surgery; and other major complications.

Infections can occur either directly at the surgical site or can be embedded within biofilms that form at the incision site, making the latter infection source difficult to treat. For this reason, prevention is important. Preventive measures include practicing hand hygiene, implementing perioperative antisepsis protocols, screening for methicillin-resistant Staphylococcus aureus (MRSA), performing decolonization, and practicing infection control. In addition to the perioperative use of systemic antimicrobial agents, other less proven modalities include the irrigation of the surgical pocket with anti-infectives; use of a Keller funnel to avoid skin contamination of the implant; placement of tunneled drain tubes; use of chlorhexidine-impregnated dressings at the drain exit site; and irrigation with antiseptic solutions within the surgical drain bulb. It should be noted, however, that the FDA has warned that rare but serious allergic reactions, including fatal anaphylaxis, have been reported with the topical use of chlorhexidine.

Diagnosis of breast implant–related infections may be difficult as early symptoms, which include erythema, may mimic expected surgical or radiation inflammatory responses. Still, early infection detection is essential to prevent biofilm formation and to salvage the implant. At the first signs of a suggestive infection, a standardized, multidisciplinary diagnostic and treatment protocol should be implemented, including laboratory testing; cultures of the wound, drain and blood; breast ultrasound; and determination of the presence of periprosthetic fluid.

Empiric treatment should be able to penetrate biofilms and should consider previously used antibiotics, as breakthrough infections occur commonly among those BC patients who have been prescribed first-generation cephalosporins during the early postoperative period. Among the most common organisms found in breast implant–related infections are MRSA (36%), methicillin-sensitive S aureus (20%), and Pseudomonas species (14%).

Outpatient antimicrobial management for mild-to-moderate infections may include oral minocycline plus rifampin. For severe infections, hospitalization is needed, and use of IV daptomycin and rifampin plus cefepime or ciprofloxacin should be considered. An IV-to-po switch should occur when the patient is clinically stable. Use of linezolid or vancomycin is not recommended, as they are not as active within the biofilm as the previously mentioned antimicrobial agents.

If additional antibiotic coverage is needed, the use of dalbavancin can be considered, as it able to penetrate the biofilm. It has prolonged effects and acts synergistically with rifampin. Once culture results are available, the patient should be treated accordingly considering biofilm activity and patient allergies or organ impairment. For severe, deep-seated infections that are responding poorly to antibiotic therapy, removal of the implant may be necessary.

The article also provides insight to complications that may mimic breast implant–related infections, such as contact dermatitis, radiation dermatitis, ADM-related hyperemia, breast skin flap ischemia and necrosis, pyoderma gangrenosum, and inflammatory BC.

As antibiotic stewards, pharmacists can play a major role in helping to prevent reconstructive breast implant–related infections. Among the ways that pharmacist can help improve the care of their BC patients undergoing reconstructive surgery is by assisting in the development of perioperative antisepsis protocols and assuring the appropriate and judicial use of systemic antimicrobial agents.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.