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How clean is Breast surgery? An audit of surgical site infection rates in breast operations

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•Breast surgery is considered as clean surgery, infection rates should be less than 2% according to Nice guidelines 2008
• Surgical site infections in Breast surgery can result in serious and costly complications
• Increases patient recovery times and morbidity
• Provides financial burden on already constrained NHS
• Can have psychological and social impact on the patient’s well being
•Identify the incidence of infection in our breast unit

• Identify factors affecting the rate of infection

• Identify methods that could reduce the infection rate

• Re audit to complete the audit loop

•All patients undergoing breast surgery (benign and malignant) were included
• Breast plastic surgery procedures were not a part of the audit
•Prospective audit with data collection for 3 consecutive months
•Patient factors including age , BMI , co-morbidities , operative details , antibiotic prophylaxis , surgeon and assistant was recorded on a SSI form created for this purpose (figure 1)
•Microsoft access and excel were used for data base collection and analysis
•Wound was assessed  at 2 weeks interval by breast team
•Wound status was further assessed thought a patient questionnaire by day 30

 (figure2 )

• Wound infection was reported and logged onto the database
•175 patients were suitable for the study
• 40 patients reported  wound problems (23%)
• 23 patients had either clinical or microbiologically proven wound infections (13%)
•120 patient received no prophylactic antibiotics,  the rest (55 patients) received prophylactic antibiotics at surgeon discretion , the rate of infection in these two groups were 15% and 9% respectively
•No correlation found between various risk factors and wound infection 
•All five surgeons had similar wound infection rate in wire and none wire procedures.
•No specific procedure had a higher rate of infection
•One surgeon used prophylactic antibiotics for all wire procedure , and this didn’t show any difference in the rate of infection 
•The data was presented to microbiology team and in view of the high infection rate and the possible benefit form prophylactic antibiotics they advised:
•Patients undergoing breast or axillary cancer surgery should receive prophylactic antibiotics
•Prophylactic antibiotics for benign breast procedures was left for the surgeons discretion 
• The antibiotics of choice was Flucloxacillin or Clindamycin in cases with  penicillin allergy
•Re-audit the infection rate after the use of prophylactic antibiotics 
•Patients having surgery for breast cancer were given a dose of prophylactic antibiotic at induction
•Using the same selection criteria and methodology
• Prospective data collection and analysis of 125 patients in a period of 3 month
•7 patients had a clinical or microbiological diagnosis of wound infection  5.6%
•Compared with the results from the first cycle , the use of prophylactic antibiotics decreased the rate of infection and was statically significant (P<0.05)
•No wound infections in benign breast procedures although only 35%  of them  had prophylactic antibiotics
•Breast Surgery carries a higher rate of wound infection than expected
•Use of prophylactic antibiotics will decrease the rate of wound infection significantly
•In our data the use of single dose prophylactic antibiotics decreased the rate of wound infection from 13 % (first cycle) to 5.6% (second cycle) and showed statistical significance
• No role for prophylactic antibiotics in benign breast procedures
•Breast units should audit their infection rates using similar data tool 
• The rate of infection in breast surgery ranges from 3 to 15 % , some publications stated it reached 36%, the use of prosthesis increase risk of infection , breast is still considered as a clean operation , yet the accepted rate of infection is between 3% to 5% (1)
• Cochrane review published in  2013 reviewed  a total of eleven studies (2867 participants), where  ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo and one study evaluated peri-operative antibiotic compared with no antibiotic.  Results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction .(2)

 

1.Melling A. Kumar S. Whetter D. Baker E. Leaper D. Local warming may enhance the effect of prophylactic antibiotics in breast surgery. European Wound Management Association 2006;1:88
2.Daniel J Jones, Frances Bunn and Sophie V Bell-Syer. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery [review]. Cochrane Database Syst. Rev9 MAR 2014 | DOI: 10.1002/14651858.CD005360
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