What is the appropriate antibiotic treatment for a breast abscess?

From the Guidelines

Breast abscesses should be treated with incision and drainage as the primary treatment, and antibiotic therapy is recommended for abscesses associated with severe or extensive disease, rapid progression, or signs of systemic illness, with empirical coverage for CA-MRSA pending culture results. According to the clinical practice guidelines by the Infectious Diseases Society of America 1, antibiotic therapy is recommended for abscesses associated with certain conditions, such as severe or extensive disease, rapid progression, or signs of systemic illness. For outpatients with purulent cellulitis, empirical therapy for CA-MRSA is recommended pending culture results, with oral antibiotic options including clindamycin, trimethoprim-sulfamethoxazole, a tetracycline, or linezolid.

Some key points to consider when treating breast abscesses include:

• Incision and drainage is the primary treatment for cutaneous abscesses, including breast abscesses 1
• Antibiotic therapy is recommended for abscesses associated with severe or extensive disease, rapid progression, or signs of systemic illness 1
• Empirical coverage for CA-MRSA is recommended pending culture results, with oral antibiotic options including clindamycin, trimethoprim-sulfamethoxazole, a tetracycline, or linezolid 1
• Cultures from abscesses and other purulent SSTIs are recommended in patients treated with antibiotic therapy, patients with severe local infection or signs of systemic illness, patients who have not responded adequately to initial treatment, and if there is concern for a cluster or outbreak 1

In terms of specific antibiotic regimens, clindamycin 300-450 mg three times daily or trimethoprim-sulfamethoxazole DS twice daily may be considered as first-line treatment options, with the choice of antibiotic depending on the patient's risk factors for MRSA and other comorbidities. It is also important to note that antibiotic therapy should always accompany drainage of the abscess, either through needle aspiration or incision and drainage, as antibiotics alone are usually insufficient. Additionally, warm compresses and pain management with acetaminophen or ibuprofen can provide symptomatic relief, and patients should seek immediate medical attention if fever persists, the abscess enlarges, or symptoms worsen despite treatment.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Serious infections – 150 to 300 mg every 6 hours. More severe infections – 300 to 450 mg every 6 hours Pediatric Patients (for children who are able to swallow capsules): Serious infections – 8 to 16 mg/kg/day (4 to 8 mg/lb/day) divided into three or four equal doses. More severe infections – 16 to 20 mg/kg/day (8 to 10 mg/lb/day) divided into three or four equal doses. The recommended antibiotic treatment for breast abscess is clindamycin. The dosage for adults with serious infections is 150 to 300 mg every 6 hours, and for more severe infections, it is 300 to 450 mg every 6 hours. For pediatric patients, the dosage is 8 to 16 mg/kg/day for serious infections and 16 to 20 mg/kg/day for more severe infections, divided into three or four equal doses. 2

From the Research

Breast Abscess Antibiotic Treatment

• The most common causative organism in breast abscesses is Staphylococcus aureus, with a significant proportion being methicillin-resistant Staphylococcus aureus (MRSA) 3, 4.
• First-line empirical antibiotics, such as amoxicillin-clavulanate, are often resistant to MRSA, highlighting the need for alternative treatments 3.
• Clindamycin and ciprofloxacin have been recommended as initial empirical therapy for breast abscesses due to their effectiveness against MRSA 3.
• A study found that all MRSA isolates were sensitive to clindamycin, trimethoprim-sulfamethoxazole, and linezolid, while only 29% were sensitive to levofloxacin 4.
• For Staphylococcus aureus bacteremia, initial treatment typically includes antibiotics active against MRSA, such as vancomycin or daptomycin, which can be adjusted based on antibiotic susceptibility results 5.
• Empirical antibiotic treatment for breast infections should provide broad-spectrum coverage, with the addition of clindamycin to flucloxacillin offering excellent coverage for all categories of breast infection 6.

Treatment Approaches

• Minimally invasive treatments, such as ultrasound-guided fine needle aspiration (FNA) or drainage placement, can be effective in treating breast abscesses, with a low conversion rate to surgery 7.
• Source control is a critical component of treating Staphylococcus aureus bacteremia and may include removal of infected intravascular or implanted devices, drainage of abscesses, and surgical debridement 5.
• A multidisciplinary approach, including collaboration with microbiology specialists, is necessary to develop evidence-based treatment guidelines for breast infections 6.