Review
Risk factors for surgical site infections after breast surgery: A systematic review and meta-analysis

https://doi.org/10.1016/j.ejso.2012.02.179Get rights and content

Abstract

Background

Breast surgical site infections (SSIs) are major sources of postoperative morbidity and mortality, and it's established that surveillance of risk factors is effective in reducing hospital-acquired infections. However, studies about risk factors for breast SSIs were still under controversy because of limited data, contradictory results and lack of uniformity.

Materials and methods

We searched the electronic database of PubMed for case–control studies about risk factors for breast SSIs, and a meta-analysis was conducted.

Results

Eight studies including 681 cases and 2064 controls were eligible, and data was combined if the risk factor was studied by at least two studies. Of the 20 possible risk factors involved, 14 were proved significant for SSIs as follows: increased age, hypertension, higher body mass index (BMI), diabetes mellitus, American society of anesthesiologists (ASA) 3 or 4, previous breast biopsy or operation, preoperative chemoradiation, conservation therapy versus other surgical approaches, hematoma, seroma, more intraoperative bleeding, postoperative drain, longer drainage time and second drainage tube placed. However, other factors like smoking habit, immediate reconstruction, axillary lymph node dissection, preoperative chemotherapy, corticosteroid usage and prophylactic antibiotic didn't show statistical significance.

Conclusions

This meta-analysis provided a list of predictable or preventable factors that could be taken measures to reduce the rate of breast SSIs and excluded some negligible factors. This could be useful for developing effective prevention and treatment policies for patients with SSIs and improving the overall quality of life.

Introduction

Surgical site infections (SSIs) are major sources of adverse operation-related events in patients undergoing surgery, including increased morbidity, psychological trauma, additional cost and delay of postoperative adjuvant therapies.1, 2 The rate of breast SSIs range from 1% to 30%, depending on definition of SSIs, type of operation, comorbidities of the patients, time of follow up, perioperative therapy and reporting institution. It's higher than other clean operations in which the infection rate is less than 5%.3, 4, 5, 6

Several studies were performed to identify risk factors for SSIs after breast procedure, but quite a few limits existed in these studies: some studies just focused on one or a small list of potential risk factors and the variant criteria of some risk factors made conclusions hard to be drawn from them7, 8, 9, 10, 11, 12; there were also some studies which had such a small sample (patients' number of SSIs < 20) that the results might be biased.13, 14, 15, 16 Besides, some results remain conflicting rather than conclusive: smoking and prolonged use of surgical drain were considered as risk factors to SSIs in some studies,7, 17 but some other results didn't show statistically significance between them,13, 14, 15, 18, 19 preoperative chemotherapy, breast reconstruction and the administration of antibiotic prophylaxis were reported to influence the incidence of SSIs in some studies,8, 19, 20; however, the opposite results were observed in other studies.13, 18, 19, 20, 21

There were also 3 cohort studies in research of risk factors for SSIs.7, 37, 38 However, patients recruited in each study were all pretreated with different influencing factors from each other. Therefore, the data from these 3 studies were not suitable to combine as a meta-analysis.

Therefore, to give surgeons more precise information to tailor their treatment to individual patients, the objective of our study was to systemically review observational case–control data to investigate possible contributing factors for SSIs after breast surgery.

Section snippets

Search strategy and selection criteria

Meta-analysis was performed as described previously.22, 23 Relevant articles were selected by searching PubMed databases (updated on November 2011), using the following terms in the searching algorithm: case–control, breast surgery or breast procedure, surgical site infections or wound infections. Two reviewers (DX and CQ) independently screened titles and abstracts of the identified papers. References in identified articles and previous reviews were also reviews for possible inclusion. We

Eligible studies

Of 513 articles, 145 studies received full text review, of which eight met our inclusion criteria. Of these eight included studies, four were in United States of America; three were in Mexico and one from China. These articles were published between the years 1998–2010, including 681 SSIs cases and 2064 controls.13, 14, 15, 16, 18, 19, 20, 21 The detailed information of the studies was shown in Table 1.

Risk factors for SSIs

Meta-analysis of combinable data was conducted, and main results were shown in Table 2. In

Discussion

This meta-analysis of eight case–control studies gave a more precise estimation of independent risk factors for breast SSIs in patients undergoing breast surgery. Meanwhile, risk factors evaluated in single study also provided some guiding suggestion for further research.

Conflict of interest

There are no conflicts of interest.

References (38)

  • W.T. Hughes et al.

    Nosocomial infections in patients with neoplastic diseases

  • C. Robstein et al.

    Determinants of clean surgical wound infections for breast procedures at an oncologic centre

    Infect Control Hosp Epidemiol

    (1992)
  • R.P. Gaynes et al.

    Surgical site infections (SSI) rates in the United States, 1992–1998: the national nosocomial infections surveillance system basic SSI risk index

    Clin Infect Dis

    (2001 Sep 1)
  • National Nosocomial Infections Surveillance System

    National nosocomial infections surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004

    Am J Infect Control

    (2004)
  • R. Platt et al.

    Prophylaxis against wound infection following herniorrhaphy or breast surgery

    J Infect Dis

    (1992)
  • E. Vandeweyer et al.

    Immediate breast reconstruction with implants and adjuvant chemotherapy: a good option?

    Acta Chir Belg

    (2003)
  • M. Cunningham et al.

    Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

    Cochrane Database Syst Rev

    (2006 Apr)
  • C. Rotstein et al.

    Determinants of clean surgical wound infections for breast procedures at an oncology center

    Infect Control Hosp Epidemiol

    (1992)
  • A.L. Vinton et al.

    Immediate breast reconstruction following mastectomy is as safe as mastectomy alone

    Arch Surg

    (1990)
  • Cited by (141)

    View all citing articles on Scopus
    c

    These authors contributed equally to this work.

    View full text