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 ultrasound-guided needle aspiration of the cystic lesion, as this approach is less invasive and allows for continued breastfeeding. This procedure should be done immediately, as the presence of a cystic lesion with thickened contents on ultrasound, combined with her symptoms of pain, heat, and tenderness, strongly suggests a breast abscess despite her current antibiotic therapy 1. The aspiration should be performed using a 16-18 gauge needle under local anesthesia, with the collected fluid sent for culture and sensitivity testing. Multiple aspirations may be needed if the abscess recurs. The patient should continue her current antibiotics, typically dicloxacillin 500mg four times daily or clindamycin 300mg four times daily if penicillin-allergic, for a total of 10-14 days 1. She should be encouraged to continue breastfeeding or expressing milk from the affected breast to promote drainage. Warm compresses applied to the breast for 15 minutes before feeding can help with milk flow and pain relief. If aspiration fails after 2-3 attempts or if the abscess is multiloculated, surgical incision and drainage may be necessary. This approach is recommended because needle aspiration is less invasive than surgical drainage, allows continued breastfeeding, and typically results in faster resolution of symptoms while the antibiotics address the underlying infection 1. Some key points to consider in the management of breast abscesses include:

• The use of antibiotics effective against Gram-positive bacteria, such as dicloxacillin or clindamycin 1
• The importance of continued breastfeeding or milk expression to promote drainage and prevent further complications 1
• The role of ultrasound-guided needle aspiration in the diagnosis and treatment of breast abscesses 1
• The potential need for surgical incision and drainage in cases where aspiration fails or the abscess is multiloculated 1

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 3, 4, 5, 6.

Treatment Options

• The patient is already on antibiotics, which is a common initial treatment for breast abscesses 2, 3, 4, 5, 6.
• Repeated aspiration (option c) is a viable treatment option, as it has been shown to be effective in managing breast abscesses, especially in lactating women 3, 4, 5, 6.
• Incision and drainage (option b) is also a treatment option, but it may be more invasive and have a higher risk of complications compared to repeated aspiration 2, 3, 4.

Recommendations

• Based on the evidence, repeated aspiration (option c) is a suitable next step in managing the patient's breast abscess, as it is a less invasive procedure with a lower risk of complications and can be performed on an outpatient basis 3, 4, 5, 6.
• Continuing antibiotics (option a) is also important, as it can help to resolve the infection and prevent further complications 2, 3, 4, 5, 6.