What is the recommended treatment for a breast abscess?

Breast Abscess Treatment

Ultrasound-guided needle aspiration combined with appropriate antibiotic therapy is the first-line treatment for breast abscesses, regardless of size. 1

Initial Management

Diagnostic Approach

• Perform physical examination to identify fluctuant masses, erythema, and warmth
• Ultrasound examination is essential to confirm diagnosis and guide treatment
• Obtain cultures during aspiration to guide targeted antibiotic therapy

Treatment Algorithm

1. First-line treatment: Ultrasound-guided needle aspiration

   • Appropriate for abscesses of any size, including those >5 cm 1
   • Multiple aspirations may be required (average 2.4 aspirations per abscess) 2
   • Benefits: outpatient procedure, easily repeatable, no cosmetic damage, preserves milk ducts, allows continued breastfeeding 1

2. Antibiotic therapy

   • All patients should receive concurrent antibiotics 3
   • First-line: Amoxicillin-clavulanic acid (covers both aerobic and anaerobic organisms)
   • Alternative for penicillin-allergic patients: Ciprofloxacin plus metronidazole 4
   • Consider MRSA coverage in high-risk patients or areas with high MRSA prevalence
   • Duration: 5-10 days for uncomplicated infections; 7-14 days for complicated infections 4

3. Follow-up

   • Reassess after 48-72 hours to ensure clinical improvement
   • Repeat aspiration as needed (may require 1-5 sessions) 1, 5
   • Consider ultrasound follow-up to monitor resolution

Alternative Approaches

1. Ultrasound-guided percutaneous catheter drainage

   • Consider for larger abscesses (>3 cm) 6, 3
   • May be more effective than repeated needle aspirations for large collections
   • Catheter can remain in place for several days to ensure complete drainage

2. Surgical incision and drainage

   • Reserve for cases where percutaneous methods fail
   • Consider as first-line for:
     • Very large (>5 cm) abscesses
     • Multiloculated abscesses
     • Long-standing abscesses
     • Failed percutaneous drainage 3
   • Disadvantages: requires general anesthesia, hospital stay, cosmetic damage, higher risk of recurrence due to milk duct disruption 1

Special Considerations

Lactational vs. Non-lactational Abscesses

• Lactational abscesses: Encourage continued breastfeeding (from unaffected breast during treatment)
• Non-lactational abscesses: Consider underlying causes (e.g., smoking, diabetes)
• Recurrent subareolar abscesses may require surgical referral for definitive management 3

Recurrent Abscesses

• Consider extended antibiotic courses
• Evaluate for underlying conditions
• Consider definitive surgical management (marsupialization or excision) for recurrent cases 4

Treatment Success Rates

• Needle aspiration success rate: 96% of cases in one study 5
• In a study of 64 breastfeeding mothers with breast abscesses, none required surgical incision and drainage when treated with antibiotics and needle aspiration 1
• Another study showed 90% success rate with percutaneous drainage methods 2

Pitfalls and Caveats

• Failure to obtain cultures may lead to ineffective antibiotic therapy
• Inadequate follow-up can result in treatment failure or recurrence
• Persistent masses after drainage should be evaluated for malignancy, especially in non-lactational abscesses 6
• Untreated or inadequately treated abscesses can lead to systemic infection
• Surgical drainage should not be automatically chosen for large abscesses, as needle aspiration can be successful even for abscesses >5 cm 1

Ultrasound-guided management without surgery has been shown to be effective regardless of abscess size, with the added benefits of preserving cosmesis and allowing continued breastfeeding in lactating women 1.