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Preventing wound infection after breast surgery

Journal of the American College of Surgeons

In addition to the negative outcomes commonly associated with all postoperative infections, including added cost related to treating the infection, extra medical visits that may be required, increased length of hospital stay, and time lost from work, wound infection after breast surgery can have additional severe consequences. Such consequences may include poor cosmesis and, in the case of breast cancer, a potentially devastating delay in adjunct chemotherapy and radiation therapy. These unique consequences make attempts to reduce wound infection after breast surgery an important goal. The literature, however, has not sufficiently answered the question of whether administration of prophylactic antibiotics can truly decrease postoperative breast infections.

Prophylactic antibiotic administration is a very brief course of an antimicrobial agent that is initiated before the surgical incision is made and that may continue for a set period of time postoperatively. The objective of this systematic review and meta-analysis (ie, the most credible form of evidence for applying evidence-based clinical practice) was to determine the efficacy of antibiotic prophylaxis on reducing wound infections in adult patients undergoing breast surgery. (1)

Using the terms "breast" and "infection," the researchers searched the Medline databases from 1966 to present as well as the Cochrane Library and PubMed databases for randomized controlled trials evaluating antimicrobial prophylaxis in people undergoing breast surgery for benign or malignant disease. Studies were included only if the participants were all 18 years of age or older and if the study compared the use of preoperative antibiotics to placebo, though the type of antibiotic was not specified beforehand. Studies using postoperative prophylactic antibiotics also were included. Outcome measures had to include at least wound infection or adverse reactions. Common statistical procedures, including relative risk (RR) using the fixed-effects model, were used to analyze the data.

Findings. Five randomized clinical trials evaluating prophylactic antimicrobials in 1,307 patients met the inclusion criteria. Broad-spectrum antibiotics including cefonicid, cefazolin, azithromycin, and amoxicillin-clavulanate were used in the trials. All the trials reported wound infections as an outcome with follow-up ranging from 10 days to six weeks. There was a combined RR of 0.60 favoring antibiotic prophylaxis, with a statistically significant 95% confidence interval (CI) of 0.45-0.81.

Clinical implications. The results of this review and meta-analysis revealed that prophylactic antibiotics significantly reduced the risk of postoperative wound infection after breast surgery. Perioperative nurses in their role as patient advocates should facilitate the routine administration of antibiotic prophylaxis to patients undergoing breast surgery. Additionally, they must understand that the timing for antibiotic prophylaxis is vitally important. Most prophylactic antibiotics should be administered and infused within 60 minutes before the initial incision, and antibiotics generally should be discontinued within 24 hours after surgery.  Wound Care Supply

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