Commentary on: In Vitro Evaluation of Common Antimicrobial Solutions Used for Breast Implant Soaking and Breast Pocket Irrigation—Parts 1 and 2

The good thing about science is that it’s true whether or not you believe in it.

Neil deGrasse Tyson¹

It is good to see this twin set of in vitro studies that look at the effectiveness of antibiotics vs antiseptics against bacteria in both their planktonic and sessile (biofilm) state.^2,3 The importance of clinical strategies to prevent bacterial attachment to implants at the time of surgery and the capacity of these strategies to collectively prevent downstream adverse events and ultimately the need for revision surgery represents an important body of translational research.⁴ The ability of laboratory science to provide objective data to answer clinically relevant questions remains the most powerful way we can, as clinicians, directly improve patient care. It is what clinician researchers devote their careers to achieving.

The findings support the utilization of povidone iodine–based solutions, which either alone or in combination with triple antibiotic solution (TAB) produced effective eradication of the 5 common pathogenic bacterial species tested.^2,3 In the United States, where the regulator ruled against the utilization of betadine irrigation, TAB proved to be an effective alternative.⁵ In time, however, species shifts and patterns of antibiotic resistance have reduced the effectiveness of TAB, and this study has certainly confirmed that. The presence of increasing protein (serum) also required higher concentrations of the antiseptic to achieve the same kill, a phenomenon that has been well documented.⁶ This is particularly relevant because the surgical implant pocket is home to a complex mix of fluid, protein, and bacteria. The other important variable that the authors highlight is contact time, showing that 1 to 2 minutes is not as effective as 5 and 10 minutes of contact.^2,3 This highlights the need for standardization of surgical protocols to ensure effectiveness. My own experience from speaking to colleagues and observing in operating rooms around the world is that there is a wide variation in what is employed and for how long. My practice involves allowing the irrigant to sit in situ in the first pocket while I complete the dissection of the second. I then leave the irrigant in the second pocket while I size the first, allowing for more than adequate contact time for both pockets.

The reasons for a shift in effectiveness of TAB reflect the increasing ability for microbes to become resistant to antimicrobial therapy.⁷ That coupled with the lack of new antibiotic treatments being developed has meant that bacteria are rapidly gaining the upper hand.⁸ While overprescription of antibiotics in medicine has been blamed for the emergence of resistant strains, the widespread utilization of antibiotics in animal husbandry and the leaching of antibiotics into wastewater have also been implicated.^9,10 The consequences, however, are dire, and in 2019, a report from the World Health Organization to the United Nations concluded that antibiotic resistance represents 1 of 2 significant threats to human health (the other being climate change).¹¹ Patients with infection from these resistant strains have a twofold increase in morbidity and mortality and generate more cost for subsequent treatments.¹² More recently, the issue of resistant organisms causing device-associated infections in orthopedic surgery has been identified as causing significantly worse outcomes and implant failure.⁸ There remain significant opportunities for the development of novel intrinsic antimicrobial resistance technologies and coupling these with medical devices.

Unlike antibiotics, antiseptics provide us with a good weapon to target bacteria. Antiseptics are part of a larger class of agents called biocides and are chemicals applied to skin or living tissue that kill or inhibit the growth of vegetative microorganisms. One of the most important contributions to modern medicine was made by Semmelweis, who showed that if physicians wash their fingers with chlorine after examinations, the morbidity and mortality from puerperal sepsis was significantly reduced.¹³ This utilization of topical antiseptics to reduce spread of disease has been put to good use during the current COVID-19 pandemic.¹⁴ Antiseptics can be divided into 2 classes based on the molecular size of their active agent.¹⁵ Small molecules (eg, free iodine released from povidone iodine) readily penetrate bacterial membranes through pores and rapidly cause oxidation of proteins within the bacterial cytoplasm. Larger molecules (eg, chlorhexidine) must adsorb to the microbial membrane before acting and therefore are sensitive to both dilution and protein loading and require longer to work. To date, resistance has been reported for large molecular antiseptics but not for small molecular antiseptics such as povidone iodine.^16,17 In fact, the small molecular antiseptics also have a wide spectrum of activity, extending to bacterial spores, fungi, and viruses, and so represent our most potent line of defense to reduce the risk of infection. These 2 studies have confirmed once again that the best weapon against residual bacterial contamination remains povidone iodine.^2,3

Based on our current scientific evidence, and now supported by these 2 studies, we should all be reaching for povidone iodine, either alone or in combination with TAB, to thoroughly irrigate our pockets for at least 5 minutes prior to inserting new breast implants. We owe it to our patients to do all we can to ensure a stable, long-term result and to minimize the need for revision surgery.

Disclosures

Professor Deva has previously coordinated research and been a consultant to Allergan (Irvine, CA), Mentor (Santa Barbara, CA), and Acelity (San Antonio, TX). He is an educator for Sientra (Santa Barbara, CA) and Establishment Labs (Motiva, Alajuela, Costa Rica).

Funding

The author received no financial support for the research, authorship, and publication of this article.

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