What is the next step in managing a lactating woman with a breast abscess, presenting with right breast pain, hot tender swelling, and ultrasound showing a cystic lesion with thickened content, already on flucloxacillin (flucloxacillin is a brand name, the generic name is also flucloxacillin, which is a type of antibiotic, specifically a penicillinase-resistant penicillin)?

Management of Breast Abscess in a Lactating Woman

The next step in managing this lactating woman with a breast abscess should be repeated aspiration, as this is the most appropriate treatment for an intact-skin, deep, <5cm breast abscess in a lactating woman already on appropriate antibiotic therapy (flucloxacillin). 1, 2

Assessment of the Current Situation

• The patient presents with right breast pain for 6 days, with a hot tender swelling lateral to the right areola 3
• No skin changes or fever are present, and the patient has already started flucloxacillin 3
• Ultrasound has confirmed a cystic lesion with thickened content, consistent with a breast abscess 4
• The patient is lactating, which is a specific clinical context that influences management decisions 5

Treatment Algorithm for Breast Abscess in Lactating Women

First-line Management (Current Status)

• Antibiotics: The patient is already on flucloxacillin, which is appropriate as Staphylococcus aureus is the most common pathogen in lactational breast abscesses (present in up to 51.3% of cases) 6
• Imaging: Ultrasound has been performed, confirming the diagnosis of a breast abscess 4

Next Step: Repeated Aspiration

• Repeated aspiration is indicated because:

  • The abscess has intact skin (no spontaneous drainage) 2
  • It appears to be <5cm based on the description 1
  • The patient is lactating 5
  • The abscess is deep (ultrasound-confirmed cystic collection) 4

• Aspiration technique:

  • Should be performed under ultrasound guidance 2
  • May require multiple sessions (average of 2.4 aspirations per abscess) 1
  • Should be continued until resolution 5

Why Repeated Aspiration is Superior to Other Options

1. Preferred over I&D (Incision and Drainage):

   • Aspiration is less invasive and can be performed as an outpatient procedure 1
   • Avoids general anesthesia and hospitalization 1
   • Better cosmetic outcome with no scarring 2
   • Success rates of 80-90% have been reported with aspiration of breast abscesses 1, 2

2. Preferred over continuing antibiotics alone:

   • Antibiotics alone are insufficient for established abscesses that require drainage 4
   • The presence of a collection on ultrasound indicates the need for drainage in addition to antibiotics 2

3. Preferred over excisional biopsy:

   • Excisional biopsy is unnecessarily invasive for a clearly diagnosed abscess 4
   • No indication for biopsy in the absence of suspicious features for malignancy 4

Ongoing Management

• Continue flucloxacillin as started 6
• Consider adding clindamycin if there's inadequate response, as breast infections can be polymicrobial 3
• Encourage continued breastfeeding from the unaffected breast 5
• Breastfeeding from the affected breast can resume once pain improves 5
• Follow-up ultrasound to confirm resolution after treatment 2

Potential Complications and Pitfalls

• Recurrence rates of approximately 33% have been reported for primary breast abscesses 3
• Inadequate drainage may lead to persistent infection 2
• Development of galactocele is a possible complication 5
• If the abscess fails to resolve after 2-3 aspirations, consider incision and drainage 1
• Always obtain cultures from aspirated material to guide antibiotic therapy if the empiric treatment fails 3