What is the next step in managing a lactating woman with a 6-day history of right breast pain, presenting with a hot and tender swelling, no skin changes, and no fever, who is already on antibiotics (AB), with ultrasound showing a cystic lesion with thickened contents?

From the Guidelines

The next step in managing this lactating woman with a breast abscess is to perform repeated aspiration of the cystic lesion. This procedure should be done immediately, as the clinical presentation and ultrasound findings strongly suggest a breast abscess despite ongoing antibiotic therapy 1. The aspirated fluid should be sent for culture and sensitivity testing to guide further antibiotic therapy. After aspiration, the patient should continue her current antibiotics, for a total of 10-14 days. The patient should be advised to continue breastfeeding or expressing milk from the affected breast to promote drainage. Warm compresses applied to the breast for 15-20 minutes before feeding can help with pain and milk flow. If the abscess recurs or doesn't improve within 2-3 days after aspiration, repeat aspiration or surgical incision and drainage may be necessary. This approach is recommended because needle aspiration is less invasive than surgical drainage, allows for continued breastfeeding, and typically results in faster resolution of symptoms while the antibiotics address the underlying infection. Some key points to consider in the management of breast cysts include:

• Simple cysts are considered benign and can be managed with therapeutic fluid aspiration if clinical symptoms persist 1.
• Complicated cysts have a low risk of malignancy and can be managed with aspiration or short-term follow-up with physical examination and ultrasonography 1.
• Complex cysts have a higher risk of malignancy and should be evaluated with tissue biopsy 1. Given the clinical presentation and ultrasound findings of a cystic lesion with thickened contents, repeated aspiration is the most appropriate next step in management, as it allows for drainage of the abscess and collection of fluid for culture and sensitivity testing, while also being less invasive than surgical incision and drainage.

From the Research

Management of Breast Abscess in a Lactating Woman

• The patient presents with a 6-day history of right breast pain, hot and tender swelling, no skin changes, and no fever, and is already on antibiotics (AB) 2, 3, 4, 5, 6.
• Ultrasound shows a cystic lesion with thickened contents, indicating a breast abscess.
• The patient's symptoms and ultrasound findings suggest the need for drainage of the abscess.

Treatment Options

• Repeated aspiration (c): This is a viable option, as studies have shown that ultrasonographically guided needle aspiration is effective in treating breast abscesses, especially in lactating women 3, 4, 5, 6.
• Incision and drainage (b): This is a more invasive option, which may be considered if repeated aspiration is not successful or if the abscess is large or complex 2.
• Continuation of antibiotics (a): While antibiotics are essential in treating breast abscesses, they may not be sufficient on their own to resolve the abscess, especially if it is large or has thickened contents 2, 3, 4, 5, 6.

Recommendations

• Based on the evidence, repeated aspiration (c) is a reasonable next step in managing the patient's breast abscess, as it is a less invasive option that can be effective in resolving the abscess and allowing the patient to continue breastfeeding 3, 4, 5, 6.
• Incision and drainage (b) may be considered if repeated aspiration is not successful or if the abscess is large or complex 2.
• The patient should continue to receive antibiotics (a) to help resolve the infection 2, 3, 4, 5, 6.