Surgical prophylaxis for breast surgery
Consider the principles for appropriate prescribing of surgical antibiotic prophylaxis (see Principles for appropriate prescribing of surgical antibiotic prophylaxis). See Breast procedures and their requirement for surgical antibiotic prophylaxis for the recommendations for surgical prophylaxis for breast surgery.
Staphylococcus aureus is the most common cause of postoperative implant infection. For patients undergoing breast reconstruction or augmentation surgery, consider preoperative screening for methicillin-susceptible and methicillin-resistant S. aureus carriage. If the results of screening are positive, perform decolonisation.
For a printable summary table of the indications and regimens for surgical antibiotic prophylaxis, see here.
|
Procedures |
Is surgical antibiotic prophylaxis indicated? |
|---|---|
|
diagnostic excisional biopsy stand-alone sentinel node biopsy lumpectomy (with or without needle or wire localisation) |
NO |
|
reduction mammoplasty simple mastectomy wide local excision axillary lymph node clearance nipple surgery all repeat or revision procedures |
YES |
|
prosthetic breast reconstruction surgery (prosthetic implant or acellular dermal matrix) autologous breast reconstruction surgery breast augmentation surgery |
YES [NB1] |
Note:
NB1: Although a single preoperative dose of surgical antibiotic prophylaxis is expected to be sufficient to prevent postoperative infection following reconstruction or augmentation surgery, there is insufficient evidence to show that a single dose of prophylaxis is as effective as 24 hours of prophylaxis. Postoperative doses can be considered but prophylaxis (intravenous or oral) should not continue beyond 24 hours, even in the presence of surgical drains adjacent to the implant. See also discussion below. | |
If prophylaxis is indicated for breast surgery, use:
cefazolin 2 g intravenously, within the 60 minutes before surgical incision; intraoperative redosing may be required (see here ). Do not give additional doses once the procedure is completed1. surgical prophylaxis, breast cefazolin
For patients colonised or infected with methicillin-resistant S. aureus (MRSA), or at increased risk of being colonised or infected with MRSA (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin to cefazolin:
vancomycin 15 mg/kg up to 2 g intravenously, started within the 120 minutes before surgical incision (recommended rate 10 mg/minute)2; intraoperative redosing may be required (see here ). Do not give additional doses once the procedure is completed1. surgical prophylaxis, breast vancomycin
For patients with immediate nonsevere or delayed nonsevere hypersensitivity to penicillins, use cefazolin, with or without vancomycin, as above. See also Surgical antibiotic prophylaxis for patients with a penicillin or cephalosporin allergy.
For patients with immediate severe or delayed severe hypersensitivity to penicillins, use vancomycin as monotherapy (see dosage above).
For breast reconstruction or augmentation surgery, there is insufficient evidence to show that a single dose of prophylaxis is as effective as 24 hours of prophylaxis. The need for postoperative doses should be considered on an individual patient basis; there may be a benefit in patients with risk factors for surgical site infection such as obesity or prior radiation therapy. Postoperative prophylaxis (intravenous or oral) should not exceed 24 hours, even in the presence of surgical drains adjacent to the implant. Extended prophylaxis is associated with an increased risk of adverse effects, including subsequent infection with resistant pathogens and Clostridioides difficile (formerly known as Clostridium difficile).
There is insufficient evidence to support the use of topical antimicrobials or antiseptics to irrigate the surgical pocket at the time of implantation, and the practice is not recommended.