The risk of surgical site infection is always present in surgery; the use of prosthetic materials is linked to an increased possibility of infection. Breast augmentation and breast reconstruction with implants are gaining popularity in developing countries. Implant infection is the main complication related to breast aesthetic and reconstructive surgery. In the present paper, we reviewed the current microbiological knowledge about implant infections, with particular attention to risk factors, diagnosis, clinical management, and antibiotic prophylaxis, focusing on reports from developing countries. After breast aesthetic surgery, up to 2.9% of patients develop a surgical site infection, with an incidence of 1.7% for acute infections and 0.8% for late infections. The rate of surgical site infection after post-mastectomy breast reconstruction is usually higher, ranging from 1% to 53%. The clinical features are not constant, and bacterial culture with antibiogram is the gold standard for diagnosis and for identification of antibiotic resistance. While waiting for culture results, empiric therapy with vancomycin and extendedspectrum penicillins or cephalosporins is recommended. Some patients require removal of the infected prosthesis. The main methods to bring down the risk of infection are strict asepsis protocol, preoperative antibiotic prophylaxis, and irrigation of the surgical pocket and implant with an antibiotic solution.Key words: breast implant infections; acute infections; late infections; fungal infections; rare infections. EpidemiologyImplant infection is the main complication related to breast aesthetic and reconstructive surgery [1]. After breast aesthetic augmentation, up to 2.9% of women are affected by infection [2], with an incidence of 1.7% for acute infections versus an incidence of 0.8% for late infections, as confirmed by retrospective cohort studies with long-term follow-ups [1]. In developing countries, this problem is even more prevalent; surgery has a 50% rate of possible complications, of which infection is the main complication [3]. The rate of surgical site infection after post-mastectomy breast reconstruction is usually higher, ranging from 1% to 53% [4,5]. In breast reconstruction, a higher rate of infection was reported with expander implants compared to reconstruction with autologous tissue such as latissimus dorsi flaps [6]. The highest rates were found in women undergoing immediate reconstruction [4]. The reported number of infections after mammary augmentation and reconstruction is lower than the real incidence, because of the lack of a surveillance network of patients based on long-time follow-ups. The economic commitment for management of implant infections is significant. Kirkland et al. [7] reported an increase of hospital permanence for surgical site infection of 6.5 days, with related health care costs. In the United States, health care costs for surgical site infection after breast surgery were estimated to be about $4,091 [7], or $574 in the outpatient setting [9]...
The NIRS is a reliable additional tool in free flap monitoring. A careful evaluation should be given to patients and surgery factors that can change the oximetry data.
Thirty-two patients affected by SSTIs including DFIs were enrolled between 2013 and 2014. Superficial swab was obtained before and after cleansing with sterile saline, and after ultrasonic debridement; deep tissue biopsy was obtained from ulcer base. Samples were diluted with 1 mL of saline, serial 10-fold dilutions to 10 were made and 50 μL of each dilution was plated onto appropriate media. Bacteria were identified by Vitek II system. Microbial load was expressed as CFU/mL. Statistical analysis was performed by χ2. Incidence of Gram positives was higher than Gram negatives (S. aureus and P. aeruginosa being the most frequent); concordance (same bacteria isolated before and after debridement) never exceeded 60%. Ultrasonic debridement significantly reduced bacterial load or even suppressed bacterial growth. While reliability of superficial swab is poor for microbiological diagnosis of SSTIs, swabbing after ultrasonic debridement and biopsy of the ulcer base may be equally reliable.
The appearance of coronavirus disease 2019 (COVID-19) has provoked a global public health emergency, spreading to more than 150 countries, 1 and Italy has been particularly affected.The COVID-19 pandemic has represented a contemporary "sui generis" challenge for healthy system requiring a sudden reorganization of hospital structures and resettlement of therapeutic algorithms. The directives of the Italian Ministry of Health indicated to postpone all nonurgent surgical procedures and outpatient services, performing only urgent interventions or procedures for oncological pathologies. On March, the American College of Surgeons published guidelines for triage of nonemergent surgical intervention during the coronavirus pandemic, based on the Elective Surgery Acuity Scale (ESAS). 2 The ESAS considers lowrisk cancer as tier 2a (deferrable whenever possible) and other cancers as tier 3 a and so not deferrable. 2 Cancer patients have an elevated risk for acquiring COVID-19 and subsequent complications because of their immunodepression, poor functional status, and frequent hospital visits and admissions. 3 Moreover, Liang et al reported that oncologic patients who underwent surgery in the 30 days before contracting COVID-19 in China developed more frequently a severe form of disease compared to those who did not underwent surgery. 4 Breast carcinoma is the most frequent malignancy among women, and its modern surgical treatment nowadays includes breast reconstruction. Given the rapid evolution of the current situation, very few data of the different breast units about the present attitude toward breast cancer management are available. 5 Breast surgeons seem to agree on the fact that delaying elective surgical procedures may be more appropriate for select cases such as clinical stage I or stage II in which 60-day delays in surgical intervention were not associated with worse oncological outcomes. 6,7 To date, no guidelines on breast reconstructive surgery have been published. The aim of this article is to report our decision-making attitude during COVID-19 emergency in the field of breast reconstruction. In line with government directives, our institution limits elective surgery to oncologic procedures, and the reconstructive time is considered an integrated part of the treatment. All admitted patients undergo a pharyngeal swab at time of hospitalization. Our breast unit delays surgical treatment for low-grade tumors and ductal carcinoma in situ, while other breast cancer patients are offered lumpectomy or mastectomy as needed. Patients are evaluated case by case by a multidisciplinary team composed by breast surgeon, oncologist, radiologist and plastic surgeon to minimize the exposure to COVID-19 without compromising oncological safety and offering the best possible aesthetic outcome. The plastic surgeon purpose should be to achieve a satisfactory aesthetic result by adopting the easiest technique, limiting as much as possible operating times, risk of postoperative complication, duration of hospitalization, and outpatient v...
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