Healthcare-Associated Infections in Breast Implant Patients
Women undergoing breast reconstruction top the list of patients at risk for surgical site infections. This is an especially traumatic fact given that many of these women have undergone a mastectomy after a breast cancer diagnosis. Due to the potential of infection, these women must wait until after they undergo radiation treatment to get the reconstruction. Surgical site infection is the leading cause of death in women after breast implantation.
Augmentation vs. Reconstruction
Breast implants are used in two types of cosmetic surgery. Breast augmentation is the voluntary implantation to enhance breast size or change the breast shape. While augmentation is common, over 286,000 conducted in 2014, according to the American Society of Plastic Surgeons, the risk of infection seems to be greater for women getting reconstructive surgery.
Reconstructive surgery using breast implants is done after the tissue is removed due to disease or trauma. Two-thirds of the infections occur in the acute post-operative period, but some can develop a considerable time after the procedure – years later in fact. This long-term risk means that patients must be monitored for signs of infections after breast reconstruction using an implant.
Risk Factors for Infection
The risk factors for infection after breast implant surgery vary. There are no studies that assess the long-term risk of infection, but since this procedure is often done in concert with a mastectomy to remove cancerous tissue, the patient’s overall health is an obvious concern. Radiotherapy increases the risk of opportunistic infections considerably.
A 2012 study published in Surgical Infections (Larchmt) assessed the risk factors specifically for patients with breast cancer. The researchers looked at 240 cases of women undergoing implant surgery. Their data showed:
- Sixteen patients, or 6.7 percent, developed a post-surgical infection
- Ninety-four percent of these cases developed the infection within six months of the procedure
- The overall mean time of infection is 95 days
The study authors recommend post-operative surveillance for woman who undergo breast implant placement. This is especially critical for women who received radiotherapy or chemotherapy after the surgery. In this study, the most common pathogen was Gram-negative bacilli.
What the Causes Post-Surgical Infections?
The exact cause of healthcare-associated infections after breast implant surgery is unclear and may not be the same in every patient. In some cases, it can be tracked back to a contaminated surface on the breast implant. Other possible origins include:
- The saline inside the implant
- Surgical equipment
- Surgical environment
- The patient’s own body – skin or mammary ducts
Studies on this subject suggest infections may also result due to seeding from remote infection sites or invasive procedures. In other words, the implant is not contaminated during the initial surgery, but becomes a growth medium for bacteria that enter the body via another open area like the sinus cavities. This would be the basis for a late infection.
Types of Pathogens
The types of pathogens involved in breast implant infections vary because the source of the infection is not always the same. In 1996, the Annuals of Plastic Surgery reported the first case of late implant infection by Clostridium perfringens, an anaerobic pathogen that grows in the human gastrointestinal tract. The cause was extensive dental work. The antecedent distant infection caused by the dental treatment led to seeding of the implant.
One article suggests that the intraluminal saline inside of the breast implants can support the growth of a number of organisms.
- Staphylococcus aureus
- Staphylococcus epidermis
- Escherichia coli
- Corynebacterium jeikeium
- Enterobacter cloacae
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
The study states that saline may also be the source of fungal infections such as Asperigillus fumigatus. Of the tested samples, researchers were able to grow seven out of 10 inoculated organisms inside a breast implant. They concluded that some types of bacteria and fungi can grow and reproduce for long periods of time inside the restricted saline environment of a breast implant after surgical reconstruction.
Non-tuberculous mycobacteria, or NTM, are of special concern. NTM is opportunistic pathogen that has become more active over the last few years. This pathogen grows rapidly and may be a primary source of bacterial infection for breast implant patients. This infection is associated with postoperative wounds and requires long-term antimicrobial therapy to eradicate.
Symptoms of a Breast Implant Infection
The symptoms of a breast implant infection would be similar to any other infection. The patient may experience:
- Flu like symptoms
- Swelling around the breast or incision site
There may be purulent drainage from an incision, lesion or even the nipple. The patient may notice the breasts are uneven due to swelling or the entire breast becomes red. Palpation of the breast can lead to severe pain.
There is some evidence that infection may play a role in the formation of capsular contracture, as well. Capsular contracture is an immune system response to a foreign material in the body. A 1981 study published in Plastic and Reconstructive Surgery found that infection caused the formation of firm, fibrous capsules that were up the three times thicker than those where there was no underlying bacterial growth.
Preventive Treatment Options
The preventive treatment will depend on the patient’s health status. Not all physicians are comfortable with antibiotic prophylaxis to prevent breast implant infections. For one thing, they may not work, because some of these infections occur due to seeding after the surgery.
Some surgeons opt for a single dose antibiotic prophylaxis to reduce the risk, but this is also inadequate. One study compared two groups of patients each receiving different antibiotic prophylaxis regiments.
- One group took both pre and postoperative antibiotic prophylaxis
- One group took one a single dose of antibiotic prophylaxis
The study showed the patients that took both pre and postoperative antibiotics had fewer infections – just 19 percent compared to 34.3 percent who took a single dose antibiotic. Prolonged use of antibiotics can be deleterious, however.
Antibiotic treatments are an effective precaution prior to any invasive procedure after the implant surgery, however. For example, a patient getting dental treatment would need to take antibiotics to prevent seeding the implant.
Self-care is a big part of the infection control formula, as well. After breast implant surgery, patients should avoid:
- Taking long baths or spending time in a hot tub until the incision heals completely
- Swimming for at least two weeks
- Touching the incision sites
- Using deodorant if the incision is the armpit until healing is complete
Following the advice of the plastic surgeon can help lower the risk of breast implant infection. Patients should always advise dentists, oral surgeons, physicians and emergency personnel that they have a breast implant.
Infection is a concern with any type of implant, whether it is breast, joint or dental. Proper environmental controls and clinical observation of the patient are critical to mitigate the risk of infections and improve patient outcomes.