Table 3.

Description of Previously Published Protocols, Including Patient Population, Protocol Components, and Outcomes

Publication	Study Design	Protocol Specifics			Outcomes
		Preoperative	Intraoperative	Postoperative
Khansa et al13)	-Submuscular TE reconstruction only: before protocol implementation (2005–2010) versus after (2010–2012)	-Chlorhexidine scrub day before and morning of surgery -Weight-based preoperative IV antibiotics 30 minutes prior to incision (cefazolin, or clindamycin if PCN allergy)	-Preoperative IV antibiotics: cefazolin, or clindamycin if PCN allergy -Chlorhexidine skin prep, draping with plastic surgery team present -Soak TE in triple-antibiotic solution after opening (50,000 units of bacitracin, 1 g of cefazolin, and 80 mg of gentamicin in 500 mL of normal saline) -Pocket irrigation with antibiotic solution prior to implant placement -Reprepare around pocket with povidone-iodine and redrape with sterile towels -TE handled only by single surgeon after glove change -TE inserted with as little skin contact as possible -± use of ADM (used serratus for inferior coverage) -Surgical drains always inserted -Layered skin closure	-Perioperative antibiotics (cefazolin, or clindamycin if PCN allergy) for 24 hours -Discharge on PO antibiotics until final drain removal -Drain removal when output ≤ 30cc/day -Expansion started 2-4 weeks postoperatively (or rapid expansion prior to radiation therapy)	-305 patients (456 total reconstructions) before protocol; 198 patients (313 total reconstructions) after protocol -Fewer patients experienced infections in protocol group (11.6% vs 18.4%, P = 0.042); fewer total infected TE in protocol patients (9.3% vs 13.2%, P = 0.097) -Protocol significantly reduced odds of infection on multivariate analysis (OR 0.45, P = 0.022)
Dassoulas et al5	-All immediate implant-based: before protocol implementation vs (2010–2014) after (implemented in 2015) -Excluded autologous reconstruction -Two breast surgeons; three plastic surgeons	-Chlorhexidine scrub three days prior to surgery (specific instruction to pay attention to axilla, chest wall, IMF -Intranasal mupirocin BID for 5 days before surgery	-Preoperative IV antibiotics: cefazolin, or clindamycin if PCN allergy -Chlorhexidine skin prep -ADM soaked in Triple-antibiotic solution (cefazolin, gentamicin, bacitracin) -Pocket irrigation with antibiotic solution AND povidone-iodine prior to implant placement -ADM placed with as little skin contact as possible -Re-prep around pocket with chlorhexidine and Redrape with sterile towels -All surgeons required to change outer gloves -Irrigate pocket again with antibiotic solution AND povidone-iodine -Soak TE/implant in triple-antibiotic solution after opening -TE/implant inserted with as little skin contact as possible -Surgical drains always inserted -Layered skin closure with Dermabond	-Discharge on PO antibiotics until final drain removal (if previous XRT, prescribed TMP-SMX double-strength BID; if not, Keflex) -Drain removal when output ≤ 30cc/day or by POD21	-235 patients (358 total reconstructions) before protocol; 85 patients (135 total reconstructions) after protocol -Reduced incidence of infection after protocol implementation (2.9% versus 9.5%, p=0.013) -Protocol independently associated with decrease infection risk (OR 0.244, p=0.021)
Knight et al14	-All immediate implant-based before protocol (2012–2014) versus after (2015–2017) -Excluded LDF and two-stage reconstructions -Excluded patients with >1 risk factor (BMI > 30, smoker, DM, radiotherapy, neoadjuvant chemotherapy) -Four breast surgeons; seven plastic surgeons	-Patient selection: only included those with ≤1 risk factor (BMI > 30, smoker, DM, radiotherapy, neoadjuvant chemotherapy) -MSSA/MRSA screening -No shaving or waxing for 48 h before surgery operation -Chlorhexidine shower the night before and morning of surgery	-Preoperative IV antibiotics: teicoplanin and gentamicin -Intraoperative personnel reduction and avoid door opening (use of locks and signs) -Reduce operative time: two surgeons for bilateral procedures -Chlorhexidine skin prep -Nipple shields for unilateral cases -Surgeons require to double glove; must change outer glove prior to implant handling -Implant handled only by single surgeon after glove change -Pocket irrigated and implant soaked in Vancomycin 1 g and Gentamicin 160 mg solution with sterile water -Implants <500 cc only -Unused sterile instruments only after implant opened -Surgical drains always inserted -Bacteriostatic suture with skin glue	-Oral doxycycline 100 mg BD until final drain removal -Drain removal when output <30 cc/day on 2 consecutive days or by day 10	-54 patients (77 total implant-based reconstructions) before protocol; 106 patients (129 total reconstructions) after protocol -Reduced rate of implant loss at three months after protocol implementation (14% vs 0%, P < 0.00001)

ADM, acellular dermal matrix; BID, bis in die; BMI, body mass index; DM, diabetes mellitus; IMF, inframammary fold; MRSA, Methicillin-resistant Staphylococcus aureus; MSSA, Methicillin-sensitive Staphylococcus aureus; PCN, penicillin; PO, per oral administration; TE, Tissue expander; TMP-SMX, trimethoprim/sulfamethoxazole; XRT, radiation therapy.