Breast periprosthetic infections treated with percutaneous ultrasound-guided drainage and local injection of antibiotic

Transcription

1 Breast periprosthetic infections treated with percutaneous ultrasound-guided drainage and local injection of antibiotic Poster No.: C-633 Congress: ECR 20 Type: Scientific Paper Authors: M. P. Becchere, C. Rubino, F. Farace, L. Simbula, G. 2 2 Cipiciani, G. B. Meloni, F. Meloni, D. Soro ; Sassari/IT, Nuoro/ IT Keywords: Breast, Interventional non-vascular, Ultrasound, Drainage, Puncture, Treatment effects, Infection, Prostheses DOI: 0.594/ecr20/C-633 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page of 3

2 Purpose Peri-prosthetic infection is the most important cause of morbidity that occurs after breast implantation; it complicates % of implantations,2. Although 2/3 of cases develop during the post-operative period, some infections may occur even years after surgery. Risk factors for peri-prosthetic infection are related to surgery complications, individual predisposition of patients and immune response to pathogens. Infection may derive from implant contaminations, surgical environment, patient's skin through mammary ducts or "seeding" from distant sites of infection (main cause of late infections, incidental to possible bacteremia). Another possible cause of infection is peri-prosthetic "biofilm", described as the adhesion of microorganisms to peri-prosthetic matrix (fibrinogen, fibronectin, collagen), that creates a barrier against antibiotics through the organization of a complex community 3. Statistically, patients with the highest risk for infection are those who underwent mastectomy for mammary cancer and/or lymphadenectomy and/or radiotherapy. Despite nowadays several therapeutical methods have been proposed, removal of the device remains the most used approach to peri-prosthetic infections, especially in the 4 event of severe and recalcitrant infections. Anyway, this choice of treatment requires a long waiting period before subsequent reinsertion, and it means a physical and psychological discomfort for patients; besides, 4 it compromises aesthetic results of the following reconstruction. Our purpose is to test and assess an alternative way, different from surgical removal of the device, that may permit the healing of infections through US-guided drainage of periprosthetic fluid and subsequent local antibiotic therapy. Methods and Materials Six patients ranging from 39 to 59 years of age (mean age 5 years), were recruited in the period between january and july 200 at Senology Unit of Institute of Radiological Sciences "C.Bompiani" - University of Sassari. Patients had radical mastectomy and sentinel node procedure; none of them underwent radiotherapy. One patient showed bilateral peri-prosthetical infection 7 years after implantation; both breast implants were treated with antibiotic therapy. Page 2 of 3

3 All patients were studied through ultrasound with high frequency probes (7-5 MHz). After detection of periprosthetic fluid through US, we performed local anesthesia and a small incision on patient's skin, then a Teflon cannula 7 G was introduced. We used the cannula to drain peri-prosthetic fluid under US- guidance, and to inject a broad-spectrum antibiotic solution (cefazoline g in one case and piperacilline 2 g + tazobactam 250 mg in the others, watered with 20 ml of sodium chloride solution) into the periprosthetic space. Drained fluid was sent to microbiological analysis (cultural examination and antibiogram); blood tests were also performed. This treatment was repeated for 5 days consecutively. Results All patients showed volumetric augmentation and pain of operated breast. Ten days after surgery, one patient had systemic and local signs of infection, skin hyperemia, fever, anemia, elevation of ESR, APC and WBC. Another patient, who had had mastectomy and reconstruction 7 years before, had prodromic sympthoms such as low-grade fever and asthenia with elevation of ESR and APC. The other patients had signs of localised inflammation, which appeared from 2 to 4 years after implantation, and didn't show signs of systemic infection. All patients had breast reconstruction through Becker-type expander prosthesis. US examination constantly showed the presence of peri-prosthetic fluid, varying from 70 ml to 50 ml; hyperechoic striae and septa were present within the fluid, most likely related to fibrin formations. Drained fluid showed muddy aspect and intense yellow colour. Microbiological analysis revealed the presence of Bacillus Asaccharolyti in one patient, and Pseudomonas Aeruginosa in the patient with severe systemic infection. In the remainder patients, microbiological examination was negative. Our treatment was successful in 5 patients (six implants); so far, follow-up is from 5 to 0 months, and during this period no relapses occurred. Page 3 of 3

4 Surgery was necessary for the patient with P. Aeruginosa infection, because of her general status compromised and high risk of systemic infection. Fig.: Extensive peri-prosthetic fluid: markedly patchy aspect is due to the presence of hyperechoic septa (Pseudomonas infection) di Sassari, Sassari, ITALY 200 Page 4 of 3

5 Fig.: Peri-prosthetic fluid: multilocular aspect di Sassari, Sassari, ITALY 200 Page 5 of 3

6 Fig.: Fibrin septa inside peri-prosthetic fluid di Sassari, Sassari, ITALY 200 Fig.: Distal extremity of cannula into the peri-prosthetic fluid di Sassari, Sassari, ITALY 200 Page 6 of 3

7 Fig.: Patient n : drainage sequence, left-to-right; introduction of the cannula into the peri-prosthetic fluid (in the first image, with the inner needle) di Sassari, Sassari, ITALY 200 Fig.: Patient n : results after 4 treatments; mild amount of fluid persists. di Sassari, Sassari, ITALY 200 Page 7 of 3

8 Fig.: Patient n : full resolution after treatment di Sassari, Sassari, ITALY 200 Images for this section: Page 8 of 3

9 Fig. : Peri-prosthetic fluid: multilocular aspect Page 9 of 3

10 Fig. 2: Extensive peri-prosthetic fluid: markedly patchy aspect is due to the presence of hyperechoic septa (Pseudomonas infection) Fig. 3: Fibrin septa inside peri-prosthetic fluid Page 0 of 3

11 Fig. 4: Distal extremity of cannula into the peri-prosthetic fluid Fig. 5: Patient n : drainage sequence, left-to-right; introduction of the cannula into the peri-prosthetic fluid (in the first image, with the inner needle) Fig. 6: Patient n : results after 4 treatments; mild amount of fluid persists. Page of 3

12 Fig. 7: Patient n : full resolution after treatment Page 2 of 3

13 Conclusion Drainage of infected material and subsequent percutaneous antibiotic injection have already been described in literature for patients with mammary abscess in whom systemic antibiotic therapy had failed (Imperiale et al obtained 27 successful results in 28 cases 5 of acute breast abscesses ). To our knowledge, in literature there are no studies like the one we've presented, and although we've got just few cases, our results show an effective option to surgery in case of peri-prosthetic infections. Thus, percutaneous antibiotic therapy can be performed as the first approach in patients with peri-prosthetic infection. References Pittet B, Montadon D, Pittet D, Infection in breast Implants, Lancet Infect Dis Feb; 5(2):94-06 Feldman EM, Kontoyiannis DP, Sharabi SE, Lee E, Kaufman Y, Heller L, Breast implant infections: is cefazoin enough?, Plast Reconstr Surg. 200 Sep; 26(3): Costerton JW, Montanaro L, Arciola CR, Biofilm in implant infections: its production and regulation, J Artif Organs Nov;28():062-8 Chun JK, Schulman MR, The infected breast prosthesis after mastectomy reconstruction: successful salvage of nine implants in eight consecutive patients, Plast Reconstr Surg Sep;20(3):58-9 Imperiale A, Zandrino F, Calabrese M, Parodi G, Massa T, Abscesses of the breast. US-guided serial percutaneous aspiration and local antibiotic therapy after unsuccessful systemic antibiotic therapy, Acta Radiol. 200 Mar;42(2):6-5 Personal Information Page 3 of 3