What are the guidelines for managing breast abscesses?

Management of Breast Abscesses

The primary treatment for breast abscesses is incision and drainage, with ultrasound-guided needle aspiration being an effective alternative to surgical drainage, especially for abscesses <5cm in diameter. 1, 2

Diagnostic Approach

• Ultrasound assessment is recommended to confirm diagnosis and guide management 2, 3
• Collect samples of abscess material for culture and sensitivity testing 4
• Differentiate between lactational and non-lactational abscesses (different microbiology)

Treatment Algorithm

1. Primary Management

• Drainage Options:
  • Ultrasound-guided needle aspiration: First-line for abscesses ≤5cm 2, 5
    • May require multiple aspirations (average 2-3)
    • Advantages: outpatient procedure, cosmetically superior, preserves milk ducts, allows continued breastfeeding
  • Incision and drainage: Consider for:
    • Abscesses that fail to resolve after repeated aspirations
    • Extensive or multiloculated abscesses
    • Abscesses with significant surrounding cellulitis

2. Antibiotic Therapy

• Empiric antibiotic therapy should be initiated after drainage 1
• Recommended regimens:
  • For lactational abscesses: Coverage for MRSA is crucial as it's the predominant organism 4
    • Clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) 1
  • For non-lactational abscesses: Broader coverage may be needed
    • Amoxicillin-clavulanate or clindamycin + ciprofloxacin 4
  • Duration: 5-10 days, individualized based on clinical response 1

3. Indications for Hospitalization

• Systemic inflammatory response syndrome (SIRS) 1
• Extensive infection with significant surrounding cellulitis
• Immunocompromised patients
• Failed outpatient management
• For inpatients: Consider IV vancomycin or linezolid for MRSA coverage 1

4. Follow-up Management

• Regular ultrasound assessment to monitor resolution
• Repeat aspiration if collection recurs or persists
• For recurrent abscesses:
  • Search for underlying causes (e.g., malignancy, chronic granulomatous conditions) 1
  • Consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes for recurrent S. aureus infections 1

Special Considerations

Lactational Abscesses

• Continue breastfeeding from unaffected breast
• Can continue breastfeeding from affected breast if not too painful and drain is not near nipple
• Express milk from affected breast if too painful to feed directly

Non-Lactational Abscesses

• Higher suspicion for underlying pathology
• Consider mammography for women >30 years to exclude malignancy 5
• Biopsy of residual mass after resolution of infection

Common Pitfalls

• Inadequate drainage leading to recurrence
• Inappropriate antibiotic selection (failing to cover MRSA in lactational abscesses)
• Missing underlying malignancy in non-lactational abscesses
• Premature cessation of breastfeeding when it could be continued

Emerging Trends

• Ultrasound-guided management without surgery is increasingly preferred, regardless of abscess size 2
• Targeted antibiotic therapy based on institutional antibiograms shows better outcomes than traditional empiric choices 4

The conservative approach with appropriate antibiotics and needle aspiration has shown excellent outcomes with minimal complications, allowing continued breastfeeding and avoiding hospitalization in most cases 2, 3.