RESEARCH ARTICLEOpen Access
Determining the use of prophylactic antibiotics in
breast cancer surgeries: a survey of practice
Sergio A Acuna1,5†, Fernando A Angarita1,5,6†, Jaime Escallon2,3, Mauricio Tawil1,4and Lilian Torregrosa1,4*
Background: Prophylactic antibiotics (PAs) are beneficial to breast cancer patients undergoing surgery because
they prevent surgical site infection (SSI), but limited information regarding their use has been published. This study
aims to determine the use of PAs prior to breast cancer surgery amongst breast surgeons in Colombia.
Methods: An online survey was distributed amongst the breast surgeon members of the Colombian Association
of Mastology, the only breast surgery society of Colombia. The scope of the questions included demographics,
clinical practice characteristics, PA prescription characteristics, and the use of PAs in common breast surgical
Results: The survey was distributed amongst eighty-eight breast surgeons of whom forty-seven responded
(response rate: 53.4%). Forty surgeons (85.1%) reported using PAs prior to surgery of which >60% used PAs during
mastectomy, axillary lymph node dissection, and/or breast reconstruction. Surgeons reported they targeted the use
of PAs in cases in which patients had any of the following SSI risk factors: diabetes mellitus, drains in situ, obesity,
and neoadjuvant therapy. The distribution of the self-reported PA dosing regimens was as follows: single pre-
operative fixed-dose (27.7%), single preoperative dose followed by a second dose if the surgery was prolonged
(44.7%), single preoperative dose followed by one or more postoperative doses for >24 hours (10.6%), and single
preoperative weight-adjusted dose (2.1%).
Conclusion: Although this group of breast surgeons is aware of the importance of PAs in breast cancer surgery
there is a discrepancy in how they use it, specifically with regards to prescription and timeliness of drug
administration. Our findings call for targeted quality-improvement initiatives, such as standardized national
guidelines, which can provide sufficient evidence for all stakeholders and therefore facilitate best practice medicine
for breast cancer surgery.
Keywords: Breast surgery, Surgical site infection, Prophylactic antibiotic
Surgical site infection (SSI) of the breast is a source of
postoperative complications that are not just limited to
prolonged hospital stay and increased hospital costs, but
also includes predisposing patients to additional medical
interventions (e.g.: surgical debridement or abscess
draining), poor aesthetic results, and psychological
trauma [1-4]. More importantly SSI can delay adjuvant
treatment , which can have a detrimental effect on a
patient’s overall survival [5,6]. Certainly preventing SSIs
in breast cancer patients is a necessary step for assuring
high-quality surgical treatment.
In order to reduce SSI rates, the general recommenda-
tion is to give prophylactic antibiotics (PAs) one hour
before starting surgery and to suspend them within the
first twenty-four hours post-surgery . Historically,
using PAs in breast surgery was thought to be unneces-
sary  given that the breast is a peripheral soft tissue
organ with no direct connection to any major body ca-
vity or visceral structure  and that breast surgeries are
typically classified as clean surgical procedures. Despite
this premise, breast cancer surgery has been reported to
* Correspondence: email@example.com
1Department of Surgery, Hospital Universitario San Ignacio, Pontificia
Universidad Javeriana, Bogotá, Colombia
4Breast and Soft Tissue Clinic, Centro Javeriano de Oncología, Bogotá,
Full list of author information is available at the end of the article
© 2012 Acuna et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Acuna et al. BMC Surgery 2012, 12:18
have higher SSI rates (1.9 - 50%) than other clean surgi-
cal procedures [1,5,6,10-23]. Furthermore there are va-
rious studies in the indexed literature describing how
PAs can decrease SSI rates in this surgical procedure .
Even with this evidence there is still no general consen-
sus in the literature  therefore, evaluating current
practice patterns amongst breast surgeons can be used
to build a framework to establish best practice guidelines
at a national level. This study aims to determine the use
of PAs prior to breast cancer surgery amongst specialists
Approval from the research ethics board at Hospital Uni-
versitario San Ignacio in Bogota, Colombia was obtained
prior to starting this study. An online survey was deve-
loped in Spanish using a commercial, Internet-based ser-
vice (Encuesta Fácil, S.L.). The survey consisted of eleven
questions (Table 1) that included the following topics:
demographics, clinical practice characteristics, and the
use of PA in common breast surgical procedures. The
questions were developed in Spanish, but for the purpose
of this publication they are provided in English.
Before distributing the survey it was validated for in-
ternal congruency and user friendliness by conducting
a small pilot study with five breast surgeons, which
were not included in the final data analysis of this
study. The survey was distributed between November
2009 and March 2010 exclusively amongst breast
surgeons in Colombia. A list of names and contact in-
formation (electronic mail) was obtained from the
national breast surgery society's database [Asociación
Colombiana de Mastología (English: Colombian Asso-
ciation of Mastology)].
Respondents were allowed to modify their answers to
previous questions, but were unable to edit or resubmit
the survey once it was completed. Answers were auto-
matically kept anonymous. A reminder was sent out to
those who had not responded two and four months after
the survey was originally distributed. No rewards or
incentives were given for completion of this survey. De-
scriptive statistical analysis was carried out using means,
medians, standard deviations, and ranges using SPSS
19.0 (IBM, Chicago, IL).
Surveys were distributed amongst all the eighty-eight
breast surgeon members of the Colombian Association
of Masology of which forty-seven completed the whole
survey (response rate: 53.4%). Demographic information
Table 1 Translated survey questions
NumberQuestion Possible answer(s)
1 In what city do you practice?
2 What is your specialty?
Choose one of the following: breast surgery, surgical oncology, general surgery,
gynecology/obstetrics, or plastic surgery.
3How many years of practice do you have in breast
4 What type of practice do you have?
Choose one of the following: Private or private/academic
5What percentage of your cases corresponds to
Choose one of the following: <25%, 25 – 49%, 50 – 75%, or >75%.
6 What is your monthly breast surgery case load?
Choose one of the following:<5 cases/month, 5 – 15 cases/month, 16 – 25
cases/month, or >25 cases/month.
7Indicate from the following list of breast surgical
procedures in which cases you administer
Select as many as are appropriate: breast conserving surgery, wire localized
excision, mastectomy, axillary lymph node dissection, sentinel lymph node
biopsy, reconstruction with flap, reconstruction with implant, terminal
conduct excision, and benign lesion excision.
8 Do you use prophylactic antibiotic in all your breast
Choose one of the following: yes or no.
9What prophylactic antibiotic do you use?
10If you use prophylactic antibiotic, how do you
Choose one of the following: single pre-operative fixed-dose, single preoperative
fixed dose followed by a second fixed dose if the surgery is prolonged, single
preoperative fixed dose followed by one or more postoperative fixed doses for
>24 hours, or single preoperative weight-adjusted dose.
11If you do not administer routine prophylactic
antibiotic, in what cases do you use it?
Select as many as are appropriate: older age, obesity, cancer, smoking, diabetes
mellitus, active skin disease, neoadjuvant therapy, use of drains in situ, and
Acuna et al. BMC Surgery 2012, 12:18
Page 2 of 6
is described in Table 2. All of the surgeons reported that
they lived in major urban areas in Colombia. Further-
more, 76.6% of the respondents practiced in academic
hospital settings. Approximately forty percent of sur-
geons reported that they performed between 5 and 15
breast surgeries per month.
Only forty surgeons (85.1%) reported that they admi-
nistered a PA before breast surgeries. The self-reported
PA dosing regimens used by this group of surgeons was
as follows: single pre-operative fixed-dose (27.7%), single
preoperative fixed dose followed by a second fixed dose
if the surgery was prolonged (44.7%), single preoperative
fixed dose followed by one or more postoperative fixed
doses for >24 hours (10.6%), and single preoperative
weight-adjusted dose (2.1%). The antibiotic of choice
was unanimously cefazolin.
Surgeons who reported using PAs were then asked
about the specific breast surgical procedure in which they
used them. The distribution of these surgical procedures
is shown in Figure 1. The most common procedures in
which PAs were administered included breast reconstruc-
tion with implant (87.2%) or flap (80.9%), mastectomy
(68.1%), and axillary lymph node dissection (61.7%). Nine-
teen surgeons (40.4%) reported that they used PAs rou-
tinely in all their breast surgeries and the remaining
twenty-eight surgeons (59.6%) stated that they used tar-
geted prophylaxis while taking into consideration various,
specific patient characteristics. The distribution of these
patient characteristics is outlined in Figure 2.
Appropriately selected and timely prophylactic anti-
microbial agents are proven to decrease SSI rates in
breast cancer patients undergoing surgical treatment
[22-24]. Surgeons may hesitate to follow this recommen-
dation because uncontrolled and injudicious use of
PAs may lead to antibiotic resistance , adverse effects
(e.g.: Clostridium difficile infection) , and increase
medical costs  because they decrease SSI symptoms
until after the patient has been discharged . Never-
theless, the benefits related to this measure outweigh the
sporadic number of complications.
Our study shows that the majority of breast surgeons
that responded to this survey use some type of PA in
breast cancer patients before surgery whether it is adminis-
tered routinely in all patients or selectively when dealing
with specific high-risk variables associated with SSI.
Nonetheless, among those surgeons that reported using
PAs the practice pattern is heterogeneous. In the litera-
ture there is evidence that this disparity is also common
amongst surgeons from other countries. For example, a
British survey reported that up to 33% of surgeons who
performed wide local excisions, mastectomies and senti-
nel lymph node biopsy used PAs . Another study
carried out in Spain reported that 52% of hospitals used
PAs in breast surgery  although a more recent
multi-centric Spanish study revealed that the rate of use
of PAs was much higher (97.81%) . These results
must be analyzed cautiously because breast cancer surge-
ries are not always carried out by breast surgeons or other
sub-specialized surgeons so there may be a bias in the way
the information is gathered.
Studies have evaluated the impact of PAs, but have
showed mixed results. Two studies reported a reduction
in SSI rates that ranged from 33 to 88% after using cefo-
taxime and azithromycin [1,22]. Other researchers have
not found any significant reduction in SSI rates [23,28,32].
Nonetheless, a Cochrane review concluded that using pre-
operative antibiotics significantly reduces the risk of SSI
(pooled risk ratio 0.71, 95% confidence interval 0.53-0.94)
in patients undergoing surgery for breast cancer when
compared with placebo or no treatment . This type of
prophylactic intervention is reported to potentially benefit
high-risk patients especially when they have any of the fol-
lowing risk factors: neoadjuvant chemotherapy, immediate
breast reconstruction, blood transfusion, obesity, and
In our study 80% of surgeons reported that they used
PAs in patients undergoing breast reconstruction. In a
survey of the members of the American Society of Plas-
tic Surgeons the use of PAs was slightly higher (>90%)
Table 2 Demographic data of survey respondents
Type of specialty, N (%)
Breast surgery 23 (48.9)
Surgical oncology5 (10.6)
General surgery6 (12.8)
Plastic surgery13 (27.7)
Years of practice in breast surgery,
Type of practice, N (%)
Private 11 (23.4)
Percentage of cases corresponding to
breast surgery, N (%)
<25 9 (19.1)
25 – 499 (19.1)
50 – 75 4 (8.5)
Volume of breast surgeries per month, N (%)
<5 cases2 (4.3)
5 – 15 cases19 (40.4)
16 – 25 cases9 (19.1)
>25 cases17 (36.2)
Acuna et al. BMC Surgery 2012, 12:18
Page 3 of 6
. The authors stated that plastic surgeons use PAs
in patients undergoing any type of cosmetic or recon-
structive breast surgery because a higher rate of SSI
would exist if they were not used and also because
these types of surgeries per se increase the risk of SSI
as they have a longer length of duration and use foreign
bodies (e.g.: implants). This concept certainly goes
along with the recommendation made by the Hospital
Infection Control Practices Advisory Committee of the
U.S. Centers for Disease Control and Prevention in
which clean procedures require antibiotic prophylaxis
when implanting foreign material and in any case
where an SSI may pose a catastrophic risk .
In addition to the standard SSI risk factors inherent to
any patient (e.g.: obesity, history of smoking, diabetes,
etc.) , breast cancer surgery patients have additional,
specific risk factors (e.g.: neoadjuvant chemotherapy, re-
operations, use of foreign bodies such as implants and
drains in situ, and post-operative seroma)  that in-
crease their susceptibility to post-operative infections.
As a result of this, breast cancer patients exceed the
1.5% SSI rate suggested for elective clean surgery
[35,36]. Accordingly, at least 40% of the breast surgeons
within our study reported that they administered PAs
specifically when their patients had any of these SSI risk
The details of drug choices amongst surveyed sur-
geons are in line with current recommendations. PAs
are typically directed against gram-positive bacteria that
comprise normal skin flora (staphylococci and strepto-
cocci). Ng et al. reported that British surgeons tend to
use amoxicillin-clavulonic acid more often than cepha-
losporins ; however at many institutions cefazolin is
preferred. For example, Codina et al. reported that the
majority (36%) of hospitals in Spain prefer cefazolin .
Studies evaluating the effectiveness of cephalosporins
to reduce breast surgery SSI have had mixed results
[20,32,37]. In the past, most breast surgery SSIs were
caused by staphylococci and streptococci [5,12,13], but
recent data suggests that there are significant rates
Figure 1 Common breast surgical procedures in which breast surgeons use prophylactic antibiotics. The most common surgical
procedures in which surgeons reported they used PAs were breast reconstruction with implant or flap, mastectomy, and axillary lymph node
Figure 2 Breast cancer patient characteristics reported to be taken into consideration for targeted prophylactic antibiotic use in breast
cancer surgery. Surgeons who reported using targeted prophylaxis considered the following patient characteristics to be the most important
ones when considering who should receive PAs: cancer, diabetes mellitus, use of drain in situ, neoadjuvant therapy, and surgical re-intervention.
Acuna et al. BMC Surgery 2012, 12:18
Page 4 of 6
(30–66.2%) of non-staphylococcal infections [35-39].
Additionally, 63% of the staphylococcal isolates have been
documented to be resistant to at least one antibiotic .
Breast surgeons should be aware of this fact and monitor
patients with complicated wounds that do not respond to
standardized treatments. In the future there may be a
need to change the PAs we are currently using.
Our survey brings to light a couple of issues regarding
standardized prescription practices that require improve-
ment in the clinical practice of breast surgeons in Co-
lombia. In this survey only 2.1% of the breast surgeons
answered that they actually weight-adjust their preopera-
tive dosing. Although cefazolin is an antibiotic with pro-
longed half-life, its ability to prevent SSI is significantly
affected by sub-optimal dosing therefore in order to as-
sure optimal drug concentrations appropriate weight
adjusted dosing and re-dosing is mandatory. On another
note, the self-reported timeliness of antibiotic adminis-
tration is compliant with current recommendations 
in 89.4% of the breast surgeons we surveyed. Despite the
fact that the majority of breast surgeons in this cohort
understand the essential role of when and how long PAs
should be administered to actually prevent SSIs, there
are a significant number of surgeons that reported they
extended the use of PAs beyond the first 24 hours post-
surgery exclusively with the intention to reduce the risk
of SSI. A similar practice pattern has been reported in
Spain in which 9% of surveyed hospitals self-reported
that their surgeons prolonged the use of PAs for over
24 hours when performing breast surgeries . Ran-
domized studies have shown that administering PAs
for only 24 hours is enough to prevent SSIs and that
prolonging its use does not provide any additional
benefit , but instead increases the risk of generating
resistant bacterial strains , nosocomial infection
, diarrhea , higher health-care costs , and
increased work load for health-care staff .
SSIs, which are commonly associated with breast cancer
surgery, require extreme attention amongst breast sur-
geons because they can take several specific actions to
decrease the incidence. One of the preventative measures
is appropriately administering PAs. Our study shows that
although our cohort of breast surgeons is aware of their
importance, variation exists in terms of how PAs are pre-
scribed, specifically with regards to dosing and timeliness.
Findings such as the ones described in this study call for
the development of targeted quality-improvement initia-
tives, such as guidelines, that can ensure best practice
medicine for breast cancer surgery in Colombia.
The authors declare that they have no competing interests.
FAA conceived the study, carried out the survey, participated in the statistical
and data analysis and the design of the study, and helped to draft the
manuscript. SAA carried out the survey, participated in the data analysis and
the design of the study, and helped to draft the manuscript. JE participated
in data analysis and helped to draft the manuscript. MT participated in the
design of the study and data analysis and helped to draft the manuscript. LT
conceived the study, carried out the survey, participated in its design and
was the main coordinator. All authors read and approved the final
The authors would like to thank the Asociación Colombiana de Mastología
for providing the contact information of their members as well all of those
who responded the questionnaire. The authors would also like to thank
Kathryn Ottolino-Perry for editing this manuscript.
1Department of Surgery, Hospital Universitario San Ignacio, Pontificia
Universidad Javeriana, Bogotá, Colombia.2Department of Surgery, University
of Toronto, Toronto, ON, Canada.3Department of Surgical Oncology, Princess
Margaret Hospital, Toronto, ON, Canada.4Breast and Soft Tissue Clinic,
Centro Javeriano de Oncología, Bogotá, Colombia.5Current address: Division
of Experimental Therapeutics, Toronto General Research Institute, University
Health Network, Toronto, ON, Canada.6Current address: Institute of Medical
Science, University of Toronto, Toronto, ON, Canada.
Received: 16 March 2012 Accepted: 18 July 2012
Published: 31 August 2012
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Cite this article as: Acuna et al.: Determining the use of prophylactic
antibiotics in breast cancer surgeries: a survey of practice. BMC Surgery
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