What is the recommended treatment for a breast abscess?

Treatment of Breast Abscess

For breast abscesses, incision and drainage combined with antibiotics is the standard approach, but ultrasound-guided needle aspiration with antibiotics is equally effective and should be preferred as first-line therapy for most cases, as it avoids general anesthesia, preserves cosmesis, and allows continued breastfeeding. 1, 2

Primary Treatment Strategy

Initial Assessment and Drainage

• Ultrasound evaluation should be performed first to confirm the presence of a fluid collection and guide intervention 2, 3
• Needle aspiration is the preferred drainage method for most breast abscesses, regardless of size, as it can be performed in the outpatient setting with local anesthesia and is easily repeatable 4, 2, 3
• Aspiration successfully treats 90% of non-lactational abscesses (19/21 patients) and avoids surgery in the majority of lactational abscesses 4, 2
• Incision and drainage should be reserved for cases where needle aspiration fails after multiple attempts (typically 3-5 aspirations), when the abscess is multiloculated and not amenable to aspiration, or when there is extensive surrounding necrotic tissue 4, 2, 5

Antibiotic Therapy

Empirical antibiotics must cover MRSA, as it is the predominant organism in breast abscesses (50.8% of Staphylococcus aureus isolates), particularly in lactational abscesses 6

First-Line Empirical Regimens:

• Clindamycin 300-450 mg orally three times daily is recommended as monotherapy for outpatient management 7, 6
• Alternative: TMP-SMX 160-800 mg twice daily (but avoid in late pregnancy and infants <2 months) 7
• Ciprofloxacin plus clindamycin is specifically recommended based on institutional resistance patterns in breast abscesses 6
• Avoid amoxicillin-clavulanate as empirical therapy, as it shows high resistance rates in breast abscess isolates 6

Duration:

• 5-10 days of antibiotics for uncomplicated cases with adequate drainage 7, 1
• Extend therapy based on clinical response if systemic signs persist or drainage is incomplete 1

When Antibiotics Are Mandatory

Antibiotics must be added to drainage in these situations:

• Systemic signs of infection (fever >38.5°C, tachycardia >110 bpm) 1
• Surrounding cellulitis extending >5 cm beyond the abscess margin 1
• Immunocompromised patients (diabetes, HIV, chronic steroids) 1
• Incomplete drainage after aspiration attempts 1
• Recurrent abscess at the same site 4, 2

Special Considerations for Lactational Abscesses

• Breastfeeding should be continued during treatment, as needle aspiration allows immediate return to nursing without mother-infant separation 2
• MRSA is significantly more common in lactational versus non-lactational abscesses (p<0.0001), making anti-MRSA coverage essential 6
• Average of 2.4 aspirations may be needed for complete resolution 4
• With appropriate management, 40.6% of women can continue breastfeeding beyond 6 months despite having had an abscess 2

Monitoring and Follow-Up

• Reassess at 48-72 hours for clinical improvement (decreased pain, swelling, fever resolution) 1
• Repeat aspiration if fluid reaccumulates on ultrasound or symptoms persist 4, 2, 5
• Consider surgical drainage only after 3-5 failed aspiration attempts or if the patient develops sepsis 4, 2
• Obtain cultures from aspirated material to guide antibiotic adjustment, particularly to identify MRSA and guide targeted therapy 2, 6

Common Pitfalls to Avoid

• Do not use amoxicillin-clavulanate empirically, as resistance is common in breast abscess organisms 6
• Do not proceed directly to incision and drainage without attempting needle aspiration first, even for abscesses >5 cm 2
• Do not advise breastfeeding cessation unnecessarily, as needle aspiration allows continued nursing 2
• Do not use antibiotics alone without drainage for established abscesses, as source control is essential 1
• Recurrence rates are similar between aspiration (20%) and incision (19%), so aspiration failure should not discourage its use as first-line therapy 5