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Invited Critique
January 1, 2008

Hospital-Associated Costs Due to Surgical Site Infection After Breast Surgery—Invited Critique

Arch Surg. 2008;143(1):61. doi:10.1001/archsurg.2007.9

One of the guiding principles when performing surgical procedures is to keep surgical infections to a minimum. It is accepted that the operating team must scrub their hands, don sterile gloves, prepare the surgical site, and use sterile instruments for the procedure. Despite these precautions, patients still experience SSIs. Mastectomy infection rates have been reported by the Centers for Disease Control and Prevention to be 2%, but references cited by Olsen and colleagues report rates from 2.8% to 25%. One reason for this variance is that many of the studies referenced by Olsen et al are more than a decade old and may not be relevant in our current practice environment. Patients undergoing breast cancer surgery today are most often treated on an outpatient basis, with drains in place for only a few days. The authors assessed the economic cost attributable to these infections by studying the hospital-associated costs of SSIs following mastectomy and breast reconstruction. They determined that the overall SSI rate was 5.3% and that cost and SSIs increased with the use of breast implants and in patients with diabetes mellitus, obesity, and more ICD-9 diagnosis codes. The authors, however, failed to include such important factors as the use of postmastectomy radiation therapy and chemotherapy and the use of oral antibiotics. Analysis of cost data without evaluation of confounding variables leaves surgeons in a quandary. How do we prevent SSIs in patients undergoing mastectomy if we do not understand all of the factors that play a role? Certainly, patients who require implants and those with donor sites associated with reconstructive surgery are at a higher risk for SSIs and require special attention. However, we also need to examine the role of adjuvant therapies in the increasing rates of SSIs in patients undergoing mastectomy. This will need to be considered before and after we put on our surgical attire to protect our patients from the pain, inconvenience, and increased costs associated with SSIs.

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