> Table of Contents > Breast Abscess
Breast Abscess
Lindsay Petersen, MD
Andrea Madrigrano, MD
image BASICS
DESCRIPTION
  • Localized collection of pus within the breast parenchyma
  • Can be associated with lactation or fistulous tracts secondary to squamous epithelial neoplasm or duct occlusion
  • System(s) affected: skin/exocrine
  • Synonym(s): mammary abscess; peripheral breast abscess; subareolar abscess; puerperal abscess
Pregnancy Considerations
Most commonly associated with postpartum lactation
EPIDEMIOLOGY
  • Predominant age
    • Puerperal abscess: lactational
    • Subareolar abscess: postmenopausal
  • Predominant sex: female
  • Higher incidence in African American women
Incidence
  • 0.1-0.5% of breastfeeding women
  • Puerperal abscess rare after first 6 weeks of lactation
ETIOLOGY AND PATHOPHYSIOLOGY
  • Delayed treatment of mastitis
  • Puerperal abscesses: blocked lactiferous duct
  • Subareolar abscess: squamous epithelial neoplasm with keratin plugs or ductal extension with associated inflammation
  • Peripheral abscess: stasis within the duct leading to microbial accumulation and secondary abscess formation
  • Microbiology
    • Staphylococcus aureus is most common cause.
    • Less common causes
      • Streptococcus pyogenes; Escherichia coli; Bacteroides
      • Corynebacterium
      • Pseudomonas
      • Proteus
  • Methicillin-resistant Staphylococcus aureus (MRSA) is increasing. Risk factors for postpartum S. aureus (SA) breast abscess have not changed with rise in community-associated MRSA.
RISK FACTORS
  • Puerperal mastitis
    • 5-11% progression to abscess:
      • Most often due to inadequate therapy
    • Risk factors (stasis):
      • Infrequent or missed feeds
      • Poor latch (1)
      • Damage or irritation of the nipple
      • Use of breast pump (2)
      • Illness in mother or baby
      • Rapid weaning
      • Blocked nipple or duct
  • General factors
    • Smoking (3)
    • Diabetes (3)
    • Rheumatoid arthritis
    • Obesity (3)
  • Medically induced factors
    • Steroids
    • Silicone/paraffin implant
    • Lumpectomy with radiation
    • Oral antibiotics during breastfeeding (mastitis) (2)
    • Topical antifungal medication during breastfeeding (mastitis) (2)
  • Nipple retraction
  • Nipple piercing (mastitis, subareolar abscess) (3)
  • Higher recurrence rate if polymicrobial abscess
GENERAL PREVENTION
Early treatment of mastitis with milk expression, antibiotics, and compresses
COMMONLY ASSOCIATED CONDITIONS
Lactation
image DIAGNOSIS
PHYSICAL EXAM
  • Fever, tachycardia
  • Erythema of overlying skin
  • Tenderness, fluctuance on palpation
  • Draining pus or skin ulceration
  • Local edema
  • Nipple and skin retraction
  • Regional lymphadenopathy
DIFFERENTIAL DIAGNOSIS
  • Carcinoma (inflammatory or primary squamous cell)
  • Engorgement
  • Galactocele
  • Tuberculosis (may be associated with HIV infection)
  • Sarcoid; granulomatous mastitis
  • Syphilis
  • Foreign body reactions (e.g., to silicone and paraffin)
  • Mammary duct ectasia
DIAGNOSTIC TESTS & INTERPRETATION
  • CBC (leukocytosis)
  • Elevated ESR
  • Ultrasound (US) helps identify fluid collection within breast tissue.
  • Culture and sensitivity of abscess fluid or expressed breast milk to identify pathogen (usually Staphylococcus or Streptococcus)
  • MRSA is an increasingly important pathogen in both lactational and nonlactational abscesses.
  • Other bacteria:
    • Nonlactational abscess and recurrent abscesses associated with anaerobic bacteria
      • E. coli, Proteus; mixed bacteria less common
  • Mammogram to rule out carcinoma (generally not in acute phase)
Diagnostic Procedures/Other
Aspiration of abscess for culture (not accurate to exclude carcinoma)
Test Interpretation
  • Squamous metaplasia of the ducts
  • Intraductal hyperplasia
  • Epithelial overgrowth
  • Fat necrosis
  • Duct ectasia
image TREATMENT
GENERAL MEASURES
  • Cold compresses for pain control
  • Important to continue to breastfeed or express milk to drain the affected breast
P.137

MEDICATION
Combination of antibiotics and drainage for cure:
  • Culture midstream sample of milk for mastitis.
  • Culture abscess fluid for breast abscess.
  • There is insufficient evidence regarding the effectiveness of antibiotic therapies for lactational mastitis alone (4)[A].
First Line
  • NSAIDs for analgesia and/or antipyresis
  • Dicloxacillin 500 mg QID for 10 to 14 days (5)[A]
  • If no response in 24 to 48 hours, switch to cephalexin 500 mg QID for 10 to 14 days.
    • Or amoxicillin-clavulanate (Augmentin) 250 to 500 mg TID
  • Clindamycin 300 mg QID if anaerobes are suspected
  • If MRSA is a concern, TMP-SMZ DS 1 to 2 PO BID for 10 to 14 days. Clindamycin 300 mg PO QID as alternative
  • Contraindications: antibiotic allergy
  • In severe infections, vancomycin as an inpatient may be necessary.
    • Dose (30 mg/kg) IV in 2 divided doses every 24 hours may be necessary until culture results are available.
    • A 3rd-generation or a combination of a beta-lactam and beta-lactamase agent may need to be added as well.
SURGERY/OTHER PROCEDURES
  • Aspiration with or without US guidance (6)[A]
  • Consider US-guided percutaneous catheter placement if abscess >3 cm (6)[A].
  • Serial aspirations under US may be necessary (q2-3d) if patients fail to respond (7)[C].
  • Needle aspiration alone (without antibiotics) may be effective for small breast abscesses (8)[A].
  • Consider incision and drainage if abscess is recurrent, chronic, or >5 cm (6)[A].
  • Biopsy nonpuerperal abscesses to rule out carcinoma.
  • Open all fistulous tracts, especially abscesses in nonlactating patients.
  • US-guided aspiration with judicious use of antibiotics is superior to incision and drainage (9)[A].
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Lecithin supplementation
  • Acupuncture may help with breast engorgement, and prevention of breast abscess (10)[A].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Outpatient, unless systemically immunocompromised or septic
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Ensure resolution to exclude carcinoma.
PATIENT EDUCATION
  • Wound care
  • Continue with breastfeeding or pumping (if breastfeeding is not possible due to location of abscess) to prevent engorgement.
PROGNOSIS
  • Complete healing expected in 8 to 10 days
  • Subareolar abscesses frequently recur, even after incision and drainage (I&D) and antibiotics; may require surgical removal of ducts
REFERENCES
1. Branch-Elliman W, Golen TH, Gold HS, et al. Risk factors for Staphylococcus aureus postpartum breast abscess. Clin Infect Dis. 2012;54(1):71-77.
2. Mediano P, Fernández L, Rodríguez JM, et al. Case-control study of risk factors for infectious mastitis in Spanish breastfeeding women. BMC Pregnancy Childbirth. 2014;14:195.
3. Gollapalli V, Liao J, Dudakovic A, et al. Risk factors for development and recurrence of primary breast abscesses. J Am Coll Surg. 2010;211(1):41-48.
4. Jahanfar S, Ng CJ, Teng CL. Antibiotics for mastitis in breastfeeding women. Cochrane Database Syst Rev. 2013;(2):CD005458.
5. Cusack L, Brennan M. Lactational mastitis and breast abscess—diagnosis and management in general practice. Aust Fam Physician. 2011;40(12):976-979.
6. Lam E, Chan T, Wiseman SM. Breast abscess: evidence based management recommendations. Expert Rev Anti Infect Ther. 2014;12(7):753-762.
7. Elder EE, Brennan M. Nonsurgical management should be first-line therapy for breast abscess. World J Surg. 2010;34(9):2257-2258.
8. Thirumalaikumar S, Kommu S. Best evidence topic reports. Aspiration of breast abscesses. Emerg Med J. 2004;21(3):333-334.
9. Naeem M, Rahimnajjad MK, Rahimnajjad NA, et al. Comparison of incision and drainage against needle aspiration for the treatment of breast abscess. Am Surg. 2012;78(11):1224-1227.
10. Mangesi L, Dowswell T. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev. 2010;(9):CD006946.
Additional Reading
  • Berná-Serna JD, Berná-Mestre JD, Galindo PJ, et al. Use of urokinase in percutaneous drainage of large breast abscesses. J Ultrasound Med. 2009;28(4):449-454.
  • Dabbas N, Chand M, Pallett A, et al. Have the organisms that cause breast abscess changed with time?—implications for appropriate antibiotic usage in primary and secondary care. Breast J. 2010;16(4):412-415.
  • Rizzo M, Gabram S, Staley C, et al. Management of breast abscesses in nonlactating women. Am Surg. 2010;76(3):292-295.
  • Trop I, Dugas A, David J, et al. Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up. Radiographics. 2011;31(6):1683-1699.
Codes
ICD10
  • N61 Inflammatory disorders of breast
  • O91.13 Abscess of breast associated with lactation
  • O91.12 Abscess of breast associated with the puerperium
Clinical Pearls
  • 5-11% of cases of puerperal mastitis go on to abscess (most often due to inadequate therapy for mastitis). Risk factors for mastitis are those that result in milk stasis (infrequent feeds, missing feeds).
  • Abscesses not associated with lactation should be treated with antibiotics that cover anaerobic bacteria.
  • The treatment of choice for most breast abscesses is the combination of antibiotics and aspiration.
  • US-guided aspiration of breast abscess is preferred to incision and drainage in most cases.
  • Continuing to empty the breast (feeding, pumping or expression of breast milk) is recommended during the presence of lactation-associated breast infection.