- Email: [email protected]
Infection Management in Patients Treated with Breast Brachytherapy
Infection Management in Patients Treated with Breast Brachytherapy Deborah J. Pallett, MS Ed, PA-C, MPAS, Robert R. Kuske, MD, Coral A. Quiet, MD, and Amanda Brown, RN, BSN Prevention or treatment of infection is an important aspect in the management of patients treated with catheter based brachytherapy. There is little in the published data to serve as a guide. In our practice prophylactic oral antibiotics are only utilized when there is a high risk of infection such as with multiple reinsertions. At the earliest sign of potential infection patients are typically placed on an antibiotic that provides good coverage of streptococcal and staphylococcal species. Infection rates are likely to be lower with meticulous care of the catheters during treatment and placement of catheters post operatively rather than at the time of lumpectomy. Some practitioners advocate for routine prophylaxis yet it remains unclear whether or not the infection rates with breast brachytherapy are high enough to warrant prophylactic antibiotics in all patients and, if so, whether prophylaxis is efficacious in reducing the rate of brachytherapy-related infection. Semin Breast Dis 10:34-36 © 2007 Elsevier Inc. All rights reserved. KEYWORDS breast brachytherapy, infection management, prophylactic antibiotics, breast cancer, partial breast irradiation
I
n studies involving a new procedure, toxicity is a major endpoint. With breast brachytherapy, assuming the dosimetry is optimized, infection is one of the most common side effects. Therefore, prevention or treatment of infection is an important aspect in the management of catheter-based brachytherapy. To underscore the importance of infection control, consider the worst case scenario: a delay in adjuvant anticancer therapy caused by wound infection that adversely impacts survival. Infection-related complications may also result in poor cosmesis, require surgical intervention, can be costly, and can cause psychological trauma. There appears to be insufficient data in the literature to answer the question of how and when to best utilize antibiotics in breast brachytherapy. Seven studies looking at toxicity and side effects associated with either multi-catheter or MammoSite brachytherapy reported a wide range of infection rates from 0.6% to as high as 16.2%.1-7 In these studies, little comment was made on the criteria utilized to define infection and the method in which antibiotics were prescribed. Prophylactic antibiotics were mentioned in two of
Arizona Oncology Services and Foundation for Cancer Research and Education, Phoenix, AZ. Address reprint requests to Deborah J. Pallet, Arizona Oncology Research and Foundation for Cancer Services and Education, 300 West Clarendon, #350, Phoenix, AZ 85013. E-mail: [email protected]
34
1092-4450/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.sembd.2007.04.004
these studies.3,5 It remains unclear whether or not the infection rate associated with brachytherapy is high enough to warrant prophylactic antibiotics in all patients and, if so, whether prophylaxis is efficacious in reducing the rate of brachytherapy-related infection. To try to establish a best practice guideline, a review of general recommendations regarding infection management in surgical procedures is necessary. Guidelines for antimicrobial prophylaxis for surgery were established in 2004 by the Medicare National Surgical Infection Prevention Project.8 The general recommendations suggest antibiotics be started within 1 hour before the incision, and it should be discontinued within 24 hours after the operation. Nearly all of the studies reviewed administered a single dose of intravenous antibiotic 1 to 2 hours before the incision. Antibiotic prophylaxis after wound closure was not found to provide any additional benefit and was discouraged given concern over the emergence of resistant bacterial strains. Breast surgery was not listed as a procedure typically requiring prophylaxis; however, a recent metaanalysis of the literature looking at antibiotic prophylaxis for preventing wound infection after breast surgery determined that prophylactic antibiotics substantially reduced the risk of postoperative wound infections.9 The presence of catheters in the breast over a 1- to 2-week period creates a unique situation. Although there is little in the literature regarding infection management in situations
Breast brachytherapy and infection management involving indwelling catheters, several comments are of interest. A study looking at short- versus long-term postoperative drainage of the axilla after axillary lymph node dissection found that infectious complications were higher in patients treated with long-term drainage.10 Another study found the presence of a drain following breast surgery to be associated with a higher rate of infection.11 Interestingly, in orthopedic arthroplasty, drains are often left in place. There is apparently no evidence that continuing antibiotic until all catheters and drains are removed will lower infection rates.8 Prophylactic antibiotics are not commonly prescribed in our practice. A small percentage of patients are felt to be at higher risk for developing an infection, such as a contaminated procedure or multiple reinsertions, and will start a course of oral antibiotics on the day of their procedure. The majority of our patients are assessed daily, and antibiotics are prescribed at the earliest potential sign of incipient infection. The criteria include more than expected breast erythema, swelling, pain, purulent drainage, or fever. Cultures are rarely obtained unless there is a purulent drainage present. One might aspirate and culture the seroma fluid in the lumpectomy cavity, but beware that each aspiration carries its own risk of causing an infection. Our practice of prescribing antibiotics at the earliest sign of infection means that symptoms are often minimal. It is likely that some treated patients do not actually have an infection but rather breast changes related to trauma, tape-burn, postepinephrine blush, or subacute radiation reaction. Fat necrosis usually does not manifest until 7 to 12 months after brachytherapy. Delayed tender swelling with erythema of fat necrosis might also be mistaken for infection. The charts of the last 30 brachytherapy patients treated on the NSABP B-39 protocol in our office were evaluated. Approximately 32% received a course of oral antibiotics. Toxicity levels higher than Grade 2 were seen in only one patient in this cohort. She was ultimately referred to an infectious disease specialist given a persistent foul smelling purulent drainage from her seroma despite multiple antibiotics. Interestingly, initial cultures grew group B Streptococcus, but further more extensive cultures ultimately revealed infection with actinmycoses and she is completing a 12-month course of amoxicillin. While an unusual pathogen, her history of diabetes and obesity likely increased her risk for an atypical and persistent infection. Numerous risk factors that predispose patients to wound infection following breast procedures have been identified.11 These include age, the American Society of Anesthesiologists physical status score, and preoperative radiation. Obesity may be a significant risk factor for infection in patients undergoing breast surgery, with the thought being that pendulous breasts provide a potential reservoir for pathogens within the inframammary folds.12 Perhaps there is a subset of higher risk patients in which prophylaxis might be clearly indicated. Our practice has evolved from intraoperative catheter insertion with an open lumpectomy site to image-guided insertions 2 to 3 weeks after the breast surgery. Infection rates have decreased, suggesting that intraoperative catheter placement is associated with a higher risk of infection. This is likely
35 due to the longer, more extensive surgery and prolonged period of time that the catheters remain in place while awaiting a final pathology report. This is consistent with the reported operative risks which include prolonged time in surgery.9,11 It is also known that infection rates are higher with more extensive procedures such as mastectomy versus lumpectomy and lowest for open biopsy.12 The literature regarding surgery involving the skin suggests that staphylococcal and streptococcal species are the most common pathogens.13 The medication used should be active against the organisms most likely to cause infection. Procedures performed in macerated, moist environments, such as in the axilla of an obese individual and in patients with diabetes, have a higher incidence of infection with Gram-negative organisms. Even in these higher risk settings, staphylococci remain the most common pathogen. Oral cephalexin and dicloxacillin in 1- to 2-g daily divided dosages provide good Gram-positive coverage. Clindamycin and macrolide antibiotics such as azithromycin are alternatives for patients with a penicillin allergy. These choices offer minimal Gram-negative or anaerobic coverage. If a Gram-negative organism is suspected, then ciprofloxacin would be a good choice; however, it has variable activity against gram-positives and anaerobes. Levofloxacin is similar to ciprofloxacin but provides better Grampositive activity. We have typically prescribed either cephalexin or azithromycin as first-line therapy with either ciprofloxacin or levofloxacin given if the symptoms persisted. There is room for difference of opinion on antibiotic choice, and each provider should utilize the medications with which they are most experienced and comfortable. We often face the dilemma of whether or not to provide prophylaxis for the prevention of bacterial endocarditis in individuals at risk for this disease. In 1997, the American Heart Association updated their recommendations for endocarditis prophylaxis.14 Current general recommendations suggest prophylaxis for patients with high- to moderate-risk conditions when undergoing dental or surgical procedures that involve the oral, respiratory, or intestinal mucosa. These procedures are thought to produce transient high levels of bacteremia. Endocarditis prophylaxis is not recommended for patients undergoing incision or biopsy of surgically scrubbed skin. There are no studies that have definitively shown that antibiotic prophylaxis provides protection against the development of endocarditis during bacteremiainducing procedures. It also appears that most cases of endocarditis are not attributable to an invasive procedure. Based on the above, it would appear that prophylaxis, even in higher risk individuals, is not indicated in patients undergoing a breast brachytherapy procedure. With that said, there is little in the way of randomized trials in patients at high risk, and it can be difficult to make the decision not to treat knowing that endocarditis is a life-threatening disease. On occasion, we have been asked by the patients’ other physicians to provide prophylaxis. If treatment is offered, the recommendations are to give 2.0 g of amoxicillin with clindamycin 600 mg or cephalexin 2.0 g for patients who are allergic to penicillin. The antibiotic is taken 1 hour before the procedure.
D.J. Pallett, et al.
36 Sterile technique at the time of catheter insertion and appropriate nursing care throughout treatment are critical to reduce infection risk. The care and cleaning of both the MammoSite and multiple 19-gauge interstitial catheters are quite similar in our practice. First, a solution of approximately 30% hydrogen peroxide in sterile water is utilized to clean around each catheter. Bacitracin ointment is then applied to each entry or exit site. Cotton-tipped applicators work well for this. The North American Contact Dermatitis Group reported a sensitivity rate of 9.2% for bacitracin.9 The most common adverse event we see with use of bacitracin is contact dermatitis (approximately 10%), and these patients are switched to Neosporin or Bactroban. Occasionally, one or more catheter buttons are tight against the skin and a split 2⫻2 gauze will be placed around the button for comfort. A dressing is then applied. For multiple catheters, one or two ABD pads are placed over the breast to cover the catheter buttons, and a Velcro surgical bra is put on to hold the dressing in place. Tape is never applied directly to the skin. The MammoSite dressing is slightly different. Two telfa pads are cut to fit around the device, and that area is covered with an ABD pad. The device itself is also enclosed in an ABD pad and a surgical bra is again used. Dressing changes are done by the nurse after every treatment. Over the weekend, each patient is given a bag of supplies and instructions on how to clean the catheters. The patient is instructed to change the dressing once a day but to avoid playing with the buttons or MammoSite caps. We ask that they avoid rolling over on the brachytherapy site in the middle of the night, use care in placement of a seatbelt, and avoid bumping the catheters as much as possible. Showering throughout treatment and for 48 to 72 hours following catheter removal is not allowed. Patients are asked to monitor their temperature and to report anything over 100.5°F to the on-call physician. Any other problems or concerns that occur over the weekend can also be reported to the physician on call so that appropriate management can be expedited. In the experience of some physicians, the clean surgical wound infection rate for breast surgery is higher than expected, and prophylactic antibiotics administered at the time of surgery are protective.10,11 The presence of catheters postoperatively has been associated with an increased infection risk.10,11 From the literature, the utility of prophylactic antibiotics is controversial, but (if given) it should be delivered just before insertion. Infection rates reported in a number of the breast brachytherapy studies vary widely and, in some, appear to be rather high.1-7 Perhaps high infection rates are
seen in institutions newly introducing a brachytherapy program and improve with time and experience. We believe that catheter insertion as a separate procedure with the lumpectomy wound healed will lower infection rates in comparison to placing catheters at the time of lumpectomy or re-excision. With more and more patients being treated with catheter-based brachytherapy, the importance of understanding the infection rate, predisposing risk factors for infection, and optimal treatment must be better understood and addressed.
References 1. Chen PY, Vicini FA, Benitez P, et al: Long-term cosmetic results and toxicity after accelerated partial-breast irradiation. Cancer 5:991-999, 2006 2. Vicini FA, Beisch PD, Quiet CA, et al: First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity. Cancer 6:1138-1148, 2005 3. Ott OJ, Hildebrandt G, Potter R: Accelerated partial breast irradiation with mult-catheter brachytherapy: local control, side effects and cosmetic outcome for 274 patients. Results of the German-Austrian multicentre trial. Radiother Oncol 1-6, 2006 4. Harper JL, Jenretter JM, Vanek KN, et al: Acute complications of mammosite brachytherpay: a single institution’s initial clinical experince. Biology 61:169-174, 2005 5. Dowlatshahi K, Snider HC, Gittleman MA, et al: Early experience with balloon brachytherapy for breast cancer. Arch Surg 139:603608, 2004 6. Strnad V, Ott O, Potter R, et al: Interstitial Brachytherapy alone after breast conserving surgery: interim results of a German-Austrian multicenter phase II trial. Brachytherapy 3:115-119, 2004 7. Baglan KL, Martinez AA, Frazier RC, et al: The use of high-dose-rate brachytherapy alone after lumpectomy in patients with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 50:1003-1011, 2001 8. Bratzler DW, Houck PM: Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. CID 38:1706-1715, 2004 9. Tejirian T, DiFronzo LA, Haigh PI: Antibiotic prophylaxis for preventing wound infection after breast surgery: a systematic review and metaanalysis. J Am Coll Surg 203:729-734, 2006 10. Baas-Vrancken Peters MJ, Kluit AB, Merkus JW, et al: Short versus long-term postoperative drainage of the axilla after axillary lymph node dissection. A prospective randomized study. Breast Cancer Res Treat 93:271-275, 2005 11. Rotstein C, Ferguson R, Cummings KM, et al: Determinants of clean surgical wound infections for breast procedures at an oncology center. Infect Control Hosp Epidemiol 13:207-214, 1992 12. Hall JC, Hall JL: Antibiotic prophylaxis for patients undergoing breast surgery. J Hosp Infect 46:165-170, 2000 13. Messingham MJ, Arpey CJ: Update on the use of antibiotics in cutaneous surgery. Dermatol Surg 3:1068-1078, 2005 14. Dajani AS, Taubert KA, Wilson W, et al: Prevention of bacterial endocarditis. JAMA 277:1794-1801, 1997
I
n studies involving a new procedure, toxicity is a major endpoint. With breast brachytherapy, assuming the dosimetry is optimized, infection is one of the most common side effects. Therefore, prevention or treatment of infection is an important aspect in the management of catheter-based brachytherapy. To underscore the importance of infection control, consider the worst case scenario: a delay in adjuvant anticancer therapy caused by wound infection that adversely impacts survival. Infection-related complications may also result in poor cosmesis, require surgical intervention, can be costly, and can cause psychological trauma. There appears to be insufficient data in the literature to answer the question of how and when to best utilize antibiotics in breast brachytherapy. Seven studies looking at toxicity and side effects associated with either multi-catheter or MammoSite brachytherapy reported a wide range of infection rates from 0.6% to as high as 16.2%.1-7 In these studies, little comment was made on the criteria utilized to define infection and the method in which antibiotics were prescribed. Prophylactic antibiotics were mentioned in two of
Arizona Oncology Services and Foundation for Cancer Research and Education, Phoenix, AZ. Address reprint requests to Deborah J. Pallet, Arizona Oncology Research and Foundation for Cancer Services and Education, 300 West Clarendon, #350, Phoenix, AZ 85013. E-mail: [email protected]
34
1092-4450/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.sembd.2007.04.004
these studies.3,5 It remains unclear whether or not the infection rate associated with brachytherapy is high enough to warrant prophylactic antibiotics in all patients and, if so, whether prophylaxis is efficacious in reducing the rate of brachytherapy-related infection. To try to establish a best practice guideline, a review of general recommendations regarding infection management in surgical procedures is necessary. Guidelines for antimicrobial prophylaxis for surgery were established in 2004 by the Medicare National Surgical Infection Prevention Project.8 The general recommendations suggest antibiotics be started within 1 hour before the incision, and it should be discontinued within 24 hours after the operation. Nearly all of the studies reviewed administered a single dose of intravenous antibiotic 1 to 2 hours before the incision. Antibiotic prophylaxis after wound closure was not found to provide any additional benefit and was discouraged given concern over the emergence of resistant bacterial strains. Breast surgery was not listed as a procedure typically requiring prophylaxis; however, a recent metaanalysis of the literature looking at antibiotic prophylaxis for preventing wound infection after breast surgery determined that prophylactic antibiotics substantially reduced the risk of postoperative wound infections.9 The presence of catheters in the breast over a 1- to 2-week period creates a unique situation. Although there is little in the literature regarding infection management in situations
Breast brachytherapy and infection management involving indwelling catheters, several comments are of interest. A study looking at short- versus long-term postoperative drainage of the axilla after axillary lymph node dissection found that infectious complications were higher in patients treated with long-term drainage.10 Another study found the presence of a drain following breast surgery to be associated with a higher rate of infection.11 Interestingly, in orthopedic arthroplasty, drains are often left in place. There is apparently no evidence that continuing antibiotic until all catheters and drains are removed will lower infection rates.8 Prophylactic antibiotics are not commonly prescribed in our practice. A small percentage of patients are felt to be at higher risk for developing an infection, such as a contaminated procedure or multiple reinsertions, and will start a course of oral antibiotics on the day of their procedure. The majority of our patients are assessed daily, and antibiotics are prescribed at the earliest potential sign of incipient infection. The criteria include more than expected breast erythema, swelling, pain, purulent drainage, or fever. Cultures are rarely obtained unless there is a purulent drainage present. One might aspirate and culture the seroma fluid in the lumpectomy cavity, but beware that each aspiration carries its own risk of causing an infection. Our practice of prescribing antibiotics at the earliest sign of infection means that symptoms are often minimal. It is likely that some treated patients do not actually have an infection but rather breast changes related to trauma, tape-burn, postepinephrine blush, or subacute radiation reaction. Fat necrosis usually does not manifest until 7 to 12 months after brachytherapy. Delayed tender swelling with erythema of fat necrosis might also be mistaken for infection. The charts of the last 30 brachytherapy patients treated on the NSABP B-39 protocol in our office were evaluated. Approximately 32% received a course of oral antibiotics. Toxicity levels higher than Grade 2 were seen in only one patient in this cohort. She was ultimately referred to an infectious disease specialist given a persistent foul smelling purulent drainage from her seroma despite multiple antibiotics. Interestingly, initial cultures grew group B Streptococcus, but further more extensive cultures ultimately revealed infection with actinmycoses and she is completing a 12-month course of amoxicillin. While an unusual pathogen, her history of diabetes and obesity likely increased her risk for an atypical and persistent infection. Numerous risk factors that predispose patients to wound infection following breast procedures have been identified.11 These include age, the American Society of Anesthesiologists physical status score, and preoperative radiation. Obesity may be a significant risk factor for infection in patients undergoing breast surgery, with the thought being that pendulous breasts provide a potential reservoir for pathogens within the inframammary folds.12 Perhaps there is a subset of higher risk patients in which prophylaxis might be clearly indicated. Our practice has evolved from intraoperative catheter insertion with an open lumpectomy site to image-guided insertions 2 to 3 weeks after the breast surgery. Infection rates have decreased, suggesting that intraoperative catheter placement is associated with a higher risk of infection. This is likely
35 due to the longer, more extensive surgery and prolonged period of time that the catheters remain in place while awaiting a final pathology report. This is consistent with the reported operative risks which include prolonged time in surgery.9,11 It is also known that infection rates are higher with more extensive procedures such as mastectomy versus lumpectomy and lowest for open biopsy.12 The literature regarding surgery involving the skin suggests that staphylococcal and streptococcal species are the most common pathogens.13 The medication used should be active against the organisms most likely to cause infection. Procedures performed in macerated, moist environments, such as in the axilla of an obese individual and in patients with diabetes, have a higher incidence of infection with Gram-negative organisms. Even in these higher risk settings, staphylococci remain the most common pathogen. Oral cephalexin and dicloxacillin in 1- to 2-g daily divided dosages provide good Gram-positive coverage. Clindamycin and macrolide antibiotics such as azithromycin are alternatives for patients with a penicillin allergy. These choices offer minimal Gram-negative or anaerobic coverage. If a Gram-negative organism is suspected, then ciprofloxacin would be a good choice; however, it has variable activity against gram-positives and anaerobes. Levofloxacin is similar to ciprofloxacin but provides better Grampositive activity. We have typically prescribed either cephalexin or azithromycin as first-line therapy with either ciprofloxacin or levofloxacin given if the symptoms persisted. There is room for difference of opinion on antibiotic choice, and each provider should utilize the medications with which they are most experienced and comfortable. We often face the dilemma of whether or not to provide prophylaxis for the prevention of bacterial endocarditis in individuals at risk for this disease. In 1997, the American Heart Association updated their recommendations for endocarditis prophylaxis.14 Current general recommendations suggest prophylaxis for patients with high- to moderate-risk conditions when undergoing dental or surgical procedures that involve the oral, respiratory, or intestinal mucosa. These procedures are thought to produce transient high levels of bacteremia. Endocarditis prophylaxis is not recommended for patients undergoing incision or biopsy of surgically scrubbed skin. There are no studies that have definitively shown that antibiotic prophylaxis provides protection against the development of endocarditis during bacteremiainducing procedures. It also appears that most cases of endocarditis are not attributable to an invasive procedure. Based on the above, it would appear that prophylaxis, even in higher risk individuals, is not indicated in patients undergoing a breast brachytherapy procedure. With that said, there is little in the way of randomized trials in patients at high risk, and it can be difficult to make the decision not to treat knowing that endocarditis is a life-threatening disease. On occasion, we have been asked by the patients’ other physicians to provide prophylaxis. If treatment is offered, the recommendations are to give 2.0 g of amoxicillin with clindamycin 600 mg or cephalexin 2.0 g for patients who are allergic to penicillin. The antibiotic is taken 1 hour before the procedure.
D.J. Pallett, et al.
36 Sterile technique at the time of catheter insertion and appropriate nursing care throughout treatment are critical to reduce infection risk. The care and cleaning of both the MammoSite and multiple 19-gauge interstitial catheters are quite similar in our practice. First, a solution of approximately 30% hydrogen peroxide in sterile water is utilized to clean around each catheter. Bacitracin ointment is then applied to each entry or exit site. Cotton-tipped applicators work well for this. The North American Contact Dermatitis Group reported a sensitivity rate of 9.2% for bacitracin.9 The most common adverse event we see with use of bacitracin is contact dermatitis (approximately 10%), and these patients are switched to Neosporin or Bactroban. Occasionally, one or more catheter buttons are tight against the skin and a split 2⫻2 gauze will be placed around the button for comfort. A dressing is then applied. For multiple catheters, one or two ABD pads are placed over the breast to cover the catheter buttons, and a Velcro surgical bra is put on to hold the dressing in place. Tape is never applied directly to the skin. The MammoSite dressing is slightly different. Two telfa pads are cut to fit around the device, and that area is covered with an ABD pad. The device itself is also enclosed in an ABD pad and a surgical bra is again used. Dressing changes are done by the nurse after every treatment. Over the weekend, each patient is given a bag of supplies and instructions on how to clean the catheters. The patient is instructed to change the dressing once a day but to avoid playing with the buttons or MammoSite caps. We ask that they avoid rolling over on the brachytherapy site in the middle of the night, use care in placement of a seatbelt, and avoid bumping the catheters as much as possible. Showering throughout treatment and for 48 to 72 hours following catheter removal is not allowed. Patients are asked to monitor their temperature and to report anything over 100.5°F to the on-call physician. Any other problems or concerns that occur over the weekend can also be reported to the physician on call so that appropriate management can be expedited. In the experience of some physicians, the clean surgical wound infection rate for breast surgery is higher than expected, and prophylactic antibiotics administered at the time of surgery are protective.10,11 The presence of catheters postoperatively has been associated with an increased infection risk.10,11 From the literature, the utility of prophylactic antibiotics is controversial, but (if given) it should be delivered just before insertion. Infection rates reported in a number of the breast brachytherapy studies vary widely and, in some, appear to be rather high.1-7 Perhaps high infection rates are
seen in institutions newly introducing a brachytherapy program and improve with time and experience. We believe that catheter insertion as a separate procedure with the lumpectomy wound healed will lower infection rates in comparison to placing catheters at the time of lumpectomy or re-excision. With more and more patients being treated with catheter-based brachytherapy, the importance of understanding the infection rate, predisposing risk factors for infection, and optimal treatment must be better understood and addressed.
References 1. Chen PY, Vicini FA, Benitez P, et al: Long-term cosmetic results and toxicity after accelerated partial-breast irradiation. Cancer 5:991-999, 2006 2. Vicini FA, Beisch PD, Quiet CA, et al: First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity. Cancer 6:1138-1148, 2005 3. Ott OJ, Hildebrandt G, Potter R: Accelerated partial breast irradiation with mult-catheter brachytherapy: local control, side effects and cosmetic outcome for 274 patients. Results of the German-Austrian multicentre trial. Radiother Oncol 1-6, 2006 4. Harper JL, Jenretter JM, Vanek KN, et al: Acute complications of mammosite brachytherpay: a single institution’s initial clinical experince. Biology 61:169-174, 2005 5. Dowlatshahi K, Snider HC, Gittleman MA, et al: Early experience with balloon brachytherapy for breast cancer. Arch Surg 139:603608, 2004 6. Strnad V, Ott O, Potter R, et al: Interstitial Brachytherapy alone after breast conserving surgery: interim results of a German-Austrian multicenter phase II trial. Brachytherapy 3:115-119, 2004 7. Baglan KL, Martinez AA, Frazier RC, et al: The use of high-dose-rate brachytherapy alone after lumpectomy in patients with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 50:1003-1011, 2001 8. Bratzler DW, Houck PM: Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. CID 38:1706-1715, 2004 9. Tejirian T, DiFronzo LA, Haigh PI: Antibiotic prophylaxis for preventing wound infection after breast surgery: a systematic review and metaanalysis. J Am Coll Surg 203:729-734, 2006 10. Baas-Vrancken Peters MJ, Kluit AB, Merkus JW, et al: Short versus long-term postoperative drainage of the axilla after axillary lymph node dissection. A prospective randomized study. Breast Cancer Res Treat 93:271-275, 2005 11. Rotstein C, Ferguson R, Cummings KM, et al: Determinants of clean surgical wound infections for breast procedures at an oncology center. Infect Control Hosp Epidemiol 13:207-214, 1992 12. Hall JC, Hall JL: Antibiotic prophylaxis for patients undergoing breast surgery. J Hosp Infect 46:165-170, 2000 13. Messingham MJ, Arpey CJ: Update on the use of antibiotics in cutaneous surgery. Dermatol Surg 3:1068-1078, 2005 14. Dajani AS, Taubert KA, Wilson W, et al: Prevention of bacterial endocarditis. JAMA 277:1794-1801, 1997