What is the management plan for a breast abscess?

Management of Breast Abscess

The cornerstone of treatment for breast abscess is ultrasound-guided needle aspiration combined with appropriate antibiotic therapy, regardless of abscess size, as this approach is less invasive, preserves cosmesis, and allows for continued breastfeeding in lactating women. 1, 2

Diagnostic Approach

• Clinical presentation: Pain, erythema, swelling, and tenderness in the breast
• Laboratory tests:
  • Complete blood count (elevated WBC)
  • C-reactive protein
  • Blood cultures (if systemic symptoms present)
• Imaging: Ultrasound is essential to confirm diagnosis and guide management 2

Treatment Algorithm

Step 1: Drainage Procedure

• First-line approach: Ultrasound-guided needle aspiration 1, 2

  • Benefits: Outpatient procedure, easily repeatable, no cosmetic damage, lower risk of recurrence, less painful, allows continued breastfeeding 2
  • Can be effective even for abscesses >5 cm in diameter 2
  • May require multiple aspirations (average 2.4 aspirations per abscess) 3

• When to consider incision and drainage:

  • Failed needle aspiration (after 2-3 attempts)
  • Large volume of pus (>20 mL) 4
  • Multiloculated abscess not amenable to aspiration
  • Delayed presentation (>7 days) 4

Step 2: Obtain Cultures

• Always obtain cultures of aspirated material before starting antibiotics when possible 1
• Test specifically for MRSA, as it is the predominant organism in breast abscesses (50.8% of S. aureus isolates) 5

Step 3: Antibiotic Therapy

For Non-Severe Cases (Outpatient Management):

• First-line empiric therapy (pending cultures):

  • Clindamycin 300-450 mg PO four times daily OR
  • Ciprofloxacin plus clindamycin combination 5

• Alternative options:

  • Amoxicillin-clavulanate 875/125 mg PO every 12 hours 1
  • Trimethoprim-sulfamethoxazole (TMP-SMX) 160-320/800-1600 mg PO q12h (for suspected MRSA) 1
  • Doxycycline 100 mg PO q12h (for suspected MRSA, not for pregnant/breastfeeding women) 1

For Severe Cases (Inpatient Management):

• First-line: Vancomycin plus piperacillin-tazobactam 1

  • Standard dosing: piperacillin-tazobactam 3.375 g IV every 6 hours or 4.5 g every 8 hours

• For penicillin-allergic patients:

  • Non-anaphylactic: Cephalexin 500 mg four times daily
  • Anaphylactic: Clindamycin 300-450 mg four times daily 1

Step 4: Duration of Therapy

• Continue IV antibiotics until clinical improvement, then transition to oral therapy
• Total duration: 7-14 days 1

Step 5: Follow-up

• Re-evaluate in 48-72 hours to assess healing progress 1
• Repeat aspiration if necessary
• Monitor for complications: spread of infection, systemic infection, recurrence, fistula formation 1

Special Considerations

Lactating vs. Non-Lactating Abscesses

• Lactational abscesses: Higher prevalence of MRSA (statistically significant difference, p<0.0001) 5
• Non-lactational abscesses: More diverse organisms including Klebsiella, Pseudomonas, Bacteroides, and occasionally Mycobacterium tuberculosis 5

Breastfeeding Recommendations

• Continued breastfeeding is encouraged and beneficial for resolution of the abscess 2
• Breastfeeding can continue from the unaffected breast
• Breastfeeding from the affected breast can resume after initial treatment if not too painful

Prevention of Recurrence

• Good hygiene practices
• Consider decolonization strategies for recurrent staphylococcal infections:
  • Intranasal mupirocin
  • Daily chlorhexidine washes
  • Daily decontamination of personal items 1

Treatment Success Rates

• Needle aspiration success rate: 82-90% 3, 4
• Factors associated with successful needle aspiration:
  • Smaller volume of pus (<5 mL)
  • Earlier presentation (<5 days) 4

This approach to breast abscess management minimizes hospitalization, preserves breast tissue and function, and allows for continued breastfeeding while effectively treating the infection.