Treatment of Nipple Discharge with Positive Bacterial Culture
Purulent nipple discharge with positive bacterial culture should be treated with appropriate systemic antibiotics based on culture sensitivities, with drainage if an abscess is present, and biopsy of the abscess wall to exclude underlying pathology. 1
Distinguishing Purulent from Other Discharge Types
Purulent discharge represents a distinct category that requires different management than other nipple discharge types 1. Key characteristics include:
- Purulent discharge indicates infection/abscess rather than the benign intraductal pathology (papillomas, duct ectasia) or malignancy typically associated with clear, serous, or bloody discharge 1
- This differs fundamentally from pathologic discharge (spontaneous, unilateral, single-duct, bloody/serous) that raises concern for malignancy 2
Treatment Algorithm for Infected Nipple Discharge
Immediate Management
- Initiate systemic antibiotics targeted to culture results 1
- Drain any identified abscess surgically 1
- Biopsy the abscess wall during drainage to exclude underlying malignancy or other pathology 1
Special Considerations for Lactating Women
- Continue breastfeeding during antibiotic treatment, as systemic antibiotics are generally compatible with lactation 3
- For HCV-positive mothers with cracked/bleeding nipples, seek specialist consultation before continuing breastfeeding 3
When Infection is Excluded
If the culture is positive but clinical presentation suggests non-infectious pathologic discharge, the standard evaluation pathway applies:
Imaging Evaluation
- Diagnostic mammography and ultrasound for women ≥40 years with pathologic discharge 2, 4
- Ultrasound alone for women <30 years 4
- Either mammography or ultrasound initially for ages 30-39 years 4
Surgical Management
- Central duct excision remains indicated for persistent pathologic discharge even after infection treatment, particularly in women >35 years or those not planning pregnancy 1
- This eliminates risk of recurrent discharge and provides definitive tissue diagnosis 1
Critical Pitfalls to Avoid
- Do not rely on negative imaging to exclude neoplasia: Mammography has 9.5% false-negative rate and cytology 17.8% false-negative rate for cancer presenting with discharge 1
- Do not treat purulent discharge with antibiotics alone without drainage if abscess is present 1
- Do not skip abscess wall biopsy: This is essential to exclude underlying malignancy masquerading as infection 1
- Do not assume infection explains all purulent discharge: In the context of widespread impetigo vulgaris or severe presentation, more aggressive treatment may be required 3