Does a breast abscess with a tract to the chest wall and free air on computed tomography (CT) require hospital admission?

From the Guidelines

Yes, a breast abscess with a tract to the chest wall and free air on CT typically requires hospital admission. This presentation suggests a complex infection that may need inpatient management with intravenous antibiotics, surgical drainage, and close monitoring. The presence of a tract to the chest wall indicates extension beyond the breast tissue, which increases the risk of spreading infection to deeper structures. Free air on CT is concerning for gas-forming organisms or possible communication with the external environment, both of which can lead to serious complications.

According to the most recent guidelines, such as those from the Infectious Diseases Society of America 1, the management of complicated infections, including those with potential for extension or severe complications, often requires a comprehensive approach including imaging, antimicrobial therapy, and sometimes surgical intervention. The use of CT scans, as mentioned in the guidelines 1 and supported by studies like those discussed in the Journal of the American College of Radiology 1, is crucial for identifying the extent of infection and guiding management.

Initial treatment would likely include broad-spectrum IV antibiotics (such as piperacillin-tazobactam 3.375g IV every 6 hours or clindamycin 600mg IV every 8 hours plus a fluoroquinolone) and surgical consultation for potential incision and drainage. Pain management, close vital sign monitoring, and serial physical examinations are essential components of care. The patient would need follow-up imaging to ensure resolution of the abscess and may require a transition to oral antibiotics (such as amoxicillin-clavulanate 875/125mg twice daily or clindamycin 300-450mg four times daily) for 7-14 days after discharge. Hospital admission allows for proper management of this potentially serious condition and helps prevent complications like sepsis or necrotizing infections.

Key considerations in the management of such cases include:

• The need for prompt and appropriate antimicrobial therapy, as emphasized in guidelines like those from the Surgical Infection Society and the Infectious Diseases Society of America 1.
• The importance of imaging, particularly CT scans, in diagnosing and managing complicated infections, as discussed in recent studies and guidelines 1.
• The potential benefits of surgical intervention, including drainage of abscesses, in selected cases, as part of a comprehensive management plan.

Overall, the management of a breast abscess with a tract to the chest wall and free air on CT requires a multidisciplinary approach, with hospital admission being a critical component for ensuring the best possible outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Breast Abscess Management

• The management of breast abscesses has evolved over time, with a shift towards less invasive procedures 2, 3, 4, 5.
• Studies have shown that needle aspiration, either with or without ultrasound guidance, can be an effective first-line treatment for breast abscesses 2, 3, 4, 5.
• Ultrasound-guided percutaneous catheter placement may be considered as an alternative approach for larger abscesses (>3 cm) 5.
• Surgical incision and drainage should be considered for first-line therapy in large (>5 cm), multiloculated, or long-standing abscesses, or if percutaneous drainage is unsuccessful 5.

Specific Considerations for Breast Abscess with Tract to Chest Wall and Free Air on CT

• There is limited direct evidence addressing the specific scenario of a breast abscess with a tract to the chest wall and free air on computed tomography (CT) 2, 6, 3, 4, 5.
• However, given the complexity of this condition, hospital admission may be necessary to ensure proper management and monitoring 2, 5.
• The presence of free air on CT suggests a possible connection between the abscess and the external environment, which may increase the risk of infection spread or other complications 5.

Antibiotic Therapy

• All patients with breast abscesses should be treated concurrently with antibiotics 6, 5.
• The choice of empirical antibiotics should be guided by local antibiograms and resistance patterns, with consideration of coverage for methicillin-resistant Staphylococcus aureus (MRSA) 6.
• Ciprofloxacin with clindamycin may be a suitable initial empirical therapy for breast abscesses, particularly in cases where MRSA is suspected 6.