Gezielte Antibiotika-Prophylaxe und Therapie periprothetischer Infektionen der Brust – Erfahrungen aus 468 konsekutiven Implantatentfernungen

Zusammenfassung

Hintergrund Periprothetische Infektionen sind gefürchtete Komplikationen sowohl der ästhetischen, als auch der rekonstruktiven Brustchirurgie. Ziel dieser Arbeit ist die Aufarbeitung der in einem Referenzzentrum für primäre und sekundäre Brustchirurgie behandelten Implantatlagerinfektionen, um eine Empfehlung zur prophylaktischen, aber auch therapeutischen antibiotischen Therapie aussprechen zu können.

Patienten und Methoden Für den Zeitraum vom 01.01.2012 bis 31.12.2015 wurden retrospektiv alle Patientinnen erfasst, bei denen ein Wechsel oder die Entfernung von Brustimplantaten erfolgt war. Anhand der Patientenakten wurden die OP-Indikationen herausgearbeitet und speziell auf Infektzeichen und Angaben zu Kapselfibrosen analysiert. Zudem wurden alle mikrobiologischen Untersuchungen dieser Eingriffe erfasst und ausgewertet.

Ergebnisse In unserer Klinik wurden im betrachteten Zeitraum 468 Implantatwechsel bzw. -explantationen bei 360 Patientinnen durchgeführt. Bei insgesamt 169 Patientinnen wurden mikrobiologische Abstrichuntersuchungen aus 245 Implantatlagern durchgeführt. Aus 23 Implantatlagern (21 Patientinnen) erfolgte ein Erregernachweis. Bei 6 weiteren Implantaten (4 Patientinnen) lagen Zeichen eines periprothetischen Infektes vor, ohne dass jedoch ein Keimnachweis gelang. In den meisten Fällen ergab die fortgeschrittene Kapselfibrose die Indikation zum Implantatwechsel. In 17 Abstrichen erfolgte ein Keimnachweis trotz fehlendem klinischen Infektverdacht. Als Erreger wurden in 17 Fällen koagulasenegative Staphylokokken, in 4 Staphylococcus aureus, und jeweils in einem Fall E. coli, Morganella morganii und Proprionibacterium acnes nachgewiesen (eine Doppelinfektion). Alle Erreger waren gegenüber Piperacillin/Tazobactam und Vancomycin sensibel, gegenüber Cefuroxim und Amoxycillin/Clavulansäure lagen jeweils eine, gegenüber Gentamycin, Ciprofloxacin und Clindamycin je 2 Resistenzen vor.

Schlussfolgerung In der Mehrzahl der Fälle ergab sich ein Keimnachweis als Zufallsbefund, während die Kapselfibrose klinisch führend war. Erreger und Resistenzlage unterschieden sich von der Mehrzahl internationaler Publikationen. Cefuroxim und Amoxycillin/Clavulansäure haben sich mit jeweils einer Resistenz als Antibiotika zur empirischen Infektprophylaxe und -therapie bewährt. Als Reserveantibiotikum, insbesondere bei fulminanten Infekten, bietet sich unter anderem Piperacillin/Tazobactam an.

Abstract

Background Periprosthetic infections are feared complications in aesthetic as well as in reconstructive breast surgery. The purpose of our study was to evaluate our institution’s specific culture data and to identify most common organisms and suitable antibiotics for prophylaxis and first line treatment in implant-based breast surgery.

Patients and Methods We analyzed all patients with a change or removal of breast implants in the period from 01.01.2012 to 31.12.2015 retrospectively. Based on the medical records, the surgical indications were identified and specifically analyzed for signs of infection and capsular fibrosis. In addition, we assessed all microbiological data of these interventions.

Results 468 implant removals or exchanges were performed in 360 patients. Microbiological smears were gathered from 169 patients (249 implants). Bacteria were cultured from 23 implants (21 patients). In 6 additional implants (four patients) a periprosthetic infection was present, without pathogen detection. In most cases, advanced capsular fibrosis was the reason for implant exchange. In 17 smears bacterial detection was carried out despite absence of clinical signs of infection. In 17 cases coagulase-negative staphylococci were detected. In 4 Staphylococcus aureus, and once each E. coli, Morganella morganii and Proprionibacterium acnes (one double infection). All pathogens were sensitive to piperacillin/tazobactam and vancomycin. One resistancy was seen to cefuroxime and amoxicillin/clavulanic acid, and 2 to gentamicin, ciprofloxacin and clindamycin.

Conclusion In the majority of cases, pathogen detection was an incidental finding, while capsular contracture caused surgical revision. Pathogens and resistance patterns found in this study differed from the majority of international publications. In our institution, Cefuroxime and amoxicillin/clavulanic acid have been proven to be a reasonable choice for prevention and treatment of periprosthetic infections. Especially in fulminant infections piperacillin/tazobactam would be our choice for initial treatment, until the specific antibiogram is available.

Schlüsselwörter

periprothetische Infektion - Mammaaugmentation - Brustrekonstruktion - Brustimplantate - Antibiotika

Key words

periprosthetic infection - breast augmentation - breast reconstruction - breast implant - antibiotics

• Literatur

• 1 Henriksen TF, Fryzek JP, Holmich LR. et al. Surgical intervention and capsular contracture after breast augmentation: a prospective study of risk factors. Annals of plastic surgery 2005; 54: 343-351
• 2 Khan UD. Breast augmentation, antibiotic prophylaxis, and infection: comparative analysis of 1 628 primary augmentation mammoplasties assessing the role and efficacy of antibiotics prophylaxis duration. Aesthetic plastic surgery 2010; 34: 42-47
• 3 Kjoller K, Holmich LR, Jacobsen PH. et al. Epidemiological investigation of local complications after cosmetic breast implant surgery in Denmark. Annals of plastic surgery 2002; 48: 229-237
• 4 Araco A, Gravante G, Araco F. et al. Infections of breast implants in aesthetic breast augmentations: a single-center review of 3 002 patients. Aesthetic plastic surgery 2007; 31: 325-329
• 5 Hvilsom GB, Holmich LR, Steding-Jessen M. et al. Delayed breast implant reconstruction: is radiation therapy associated with capsular contracture or reoperations?. Annals of plastic surgery 2012; 68: 246-252
• 6 Seng P, Bayle S, Alliez A. et al. The microbial epidemiology of breast implant infections in a regional referral centre for plastic and reconstructive surgery in the south of France. International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases 2015; 35: 62-66
• 7 Chidester JR, Danci I, Lewis P. et al. Antibiogram for Periprosthetic Infections: A Tool for Better Informed Selection of Empiric Antibiotics for Surgical Site Infections. Annals of plastic surgery 2016; 76 (Suppl. 03) S158-S161
• 8 Phillips BT, Bishawi M, Dagum AB. et al. A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence?. Plastic and reconstructive surgery 2013; 131: 1-13
• 9 Warren Peled A, Itakura K, Foster RD. et al. Impact of chemotherapy on postoperative complications after mastectomy and immediate breast reconstruction. rchives of surgery 2010; 145: 880-885
• 10 Jones G. Breast augmentation. In: Nahai F. (Hrsg.) The art of aesthetic surgery. Quality Medical Publishing; St. Louis, Missouri: 2011: 2233-2278
• 11 Hardwicke JT, Bechar J, Skillman JM. Are systemic antibiotics indicated in aesthetic breast surgery? A systematic review of the literature. Plastic and reconstructive surgery 2013; 131: 1395-1403
• 12 Amland PF, Andenaes K, Samdal F. et al. A prospective, double-blind, placebo-controlled trial of a single dose of azithromycin on postoperative wound infections in plastic surgery. Plastic and reconstructive surgery 1995; 96: 1378-1383
• 13 Pittet B, Montandon D, Pittet D. Infection in breast implants. The Lancet Infectious diseases 2005; 5: 94-106
• 14 Brand KG. Infection of mammary prostheses: a survey and the question of prevention. Annals of plastic surgery 1993; 30: 289-295
• 15 Holm C, Muhlbauer W. Toxic shock syndrome in plastic surgery patients: case report and review of the literature. Aesthetic plastic surgery 1998; 22: 180-184
• 16 Spear SL, Seruya M. Management of the infected or exposed breast prosthesis: a single surgeon's 15-year experience with 69 patients. Plastic and reconstructive surgery 2010; 125: 1074-1084
• 17 Prince MD, Suber JS, Aya-Ay ML. et al. Prosthesis salvage in breast reconstruction patients with periprosthetic infection and exposure. Plastic and reconstructive surgery 2012; 129: 42-48
• 18 Feldman EM, Kontoyiannis DP, Sharabi SE. et al. Breast implant infections: is cefazolin enough?. Plastic and reconstructive surgery 2010; 126: 779-785
• 19 Weichman KE, Levine SM, Wilson SC. et al. Antibiotic selection for the treatment of infectious complications of implant-based breast reconstruction. Annals of plastic surgery 2013; 71: 140-143
• 20 Cohen JB, Carroll C, Tenenbaum MM. et al. Breast implant-associated infections: the role of the national surgical quality improvement program and the local microbiome. Plastic and reconstructive surgery 2015; 136: 921-929
• 21 Vinh DC, Rendina A, Turner R. et al. Breast implant infection with Mycobacterium fortuitum group: report of case and review. The Journal of infection 2006; 52: e63-e67
• 22 Thornton JW, Argenta LC, McClatchey KD. et al. Studies on the endogenous flora of the human breast. Annals of plastic surgery 1988; 20: 39-42
• 23 Rieger UM, Mesina J, Kalbermatten DF. et al. Bacterial biofilms and capsular contracture in patients with breast implants. The British journal of surgery 2013; 100: 768-774
• 24 Embrey M, Adams EE, Cunningham B. et al. A review of the literature on the etiology of capsular contracture and a pilot study to determine the outcome of capsular contracture interventions. Aesthetic plastic surgery 1999; 23: 197-206
• 25 Bergmann PA, Tamouridis G, Lohmeyer JA. et al. The effect of a bacterial contamination on the formation of capsular contracture with polyurethane breast implants in comparison with textured silicone implants: an animal study. Journal of plastic, reconstructive & aesthetic surgery: JPRAS 2014; 67: 1364-1370
• 26 Netscher DT, Weizer G, Wigoda P. et al. Clinical relevance of positive breast periprosthetic cultures without overt infection. Plastic and reconstructive surgery 1995; 96: 1125-1129
• 27 Pajkos A, Deva AK, Vickery K. et al. Detection of subclinical infection in significant breast implant capsules. Plastic and reconstructive surgery 2003; 111: 1605-1611
• 28 Kuehlmann B, Prantl L. Die Zeit ist reif für ein deutschlandweit verpflichtendes Brustimplantateregister – Pilotprojekt Brustimplantate Erhebungsbogen. Handchirurgie, Mikrochirurgie, plastische Chirurgie 2016; 48: 199-204
• 29 Gfrerer L, Mattos D, Mastroianni M. et al. Assessment of patient factors, surgeons, and surgeon teams in immediate implant-based breast reconstruction outcomes. Plastic and reconstructive surgery 2015; 135: 245e-252e
• 30 Nahabedian MY, Tsangaris T, Momen B. et al. Infectious complications following breast reconstruction with expanders and implants. Plastic and reconstructive surgery 2003; 112: 467-476
• 31 Francis SH, Ruberg RL, Stevenson KB. et al. Independent risk factors for infection in tissue expander breast reconstruction. Plastic and reconstructive surgery 2009; 124: 1790-1796
• 32 Reish RG, Damjanovic B, Austen Jr. WG. et al. Infection following implant-based reconstruction in 1952 consecutive breast reconstructions: salvage rates and predictors of success. Plastic and reconstructive surgery 2013; 131: 1223-1230
• 33 Krueger EA, Wilkins EG, Strawderman M. et al. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. International journal of radiation oncology, biology, physics 2001; 49: 713-721
• 34 Disa JJ, Ad-El DD, Cohen SM. et al. The premature removal of tissue expanders in breast reconstruction. Plastic and reconstructive surgery 1999; 104: 1662-1665
• 35 Pinsolle V, Grinfeder C, Mathoulin-Pelissier S. et al. Complications analysis of 266 immediate breast reconstructions. Journal of plastic, reconstructive & aesthetic surgery: JPRAS 2006; 59: 1017-1024
• 36 McCarthy CM, Disa JJ, Pusic AL. et al. The effect of closed-suction drains on the incidence of local wound complications following tissue expander/implant reconstruction: a cohort study. Plastic and reconstructive surgery 2007; 119: 2018-2022
• 37 Armstrong RW, Berkowitz RL, Bolding F. Infection following breast reconstruction. Annals of plastic surgery 1989; 23: 284-288
• 38 Yalanis GC, Liu EW, Cheng HT. Efficacy and safety of povidone-iodine irrigation in reducing the risk of capsular contracture in aesthetic breast augmentation: a systematic review and meta-analysis. Plastic and reconstructive surgery 2015; 136: 687-698
• 39 Giordano S, Peltoniemi H, Lilius P. et al. Povidone-iodine combined with antibiotic topical irrigation to reduce capsular contracture in cosmetic breast augmentation: a comparative study. Aesthetic surgery journal/the American Society for Aesthetic Plastic surgery 2013; 33: 675-680
• 40 Adams Jr. WP, Conner WC, Barton Jr. FE. et al. Optimizing breast-pocket irrigation: the post-betadine era. Plastic and reconstructive surgery 2001; 107: 1596-1601
• 41 Pfeiffer P, Jorgensen S, Kristiansen TB. et al. Protective effect of topical antibiotics in breast augmentation. Plastic and reconstructive surgery 2009; 124: 629-634
• 42 Sukhova I, Müller D, Eisenmann-Klein M. et al. Quo vadis? Brustimplantate – aktuelle Entwicklungen und neue Konzepte. Handchirurgie, Mikrochirurgie, plastische Chirurgie 2012; 44: 240-253
• 43 Khoo LS, Radwanski HN, Senna-Fernandes V et al. Does the use of Intraoperative breast sizers increase complication rates in primary breast augmentation? a retrospective analysis of 416 consecutive cases in a single institution. Plastic surgery international 2016; 2016: 6584810.
• 44 Ramos-Gallardo G, Cuenca-Pardo J, Rodriguez-Olivares E et al. Breast implant and anaplastic large cell lymphoma meta-analysis. Journal of investigative surgery: the official journal of the Academy of Surgical Research 2016 doi: 10.1080/08941939.2016.1215576: 1–10
• 45 Raad I, Darouiche R, Hachem R. et al. Antibiotics and prevention of microbial colonization of catheters. Antimicrobial agents and chemotherapy 1995; 39: 2397-2400
• 46 Courtiss EH, Goldwyn RM, Anastasi GW. The fate of breast implants with infections around them. Plastic and reconstructive surgery 1979; 63: 812-816
• 47 Spear SL, Howard MA, Boehmler JH. et al. The infected or exposed breast implant: management and treatment strategies. Plastic and reconstructive surgery 2004; 113: 1634-1644
• 48 Yii NW, Khoo CT. Salvage of infected expander prostheses in breast reconstruction. Plastic and reconstructive surgery 2003; 111: 1087-1092