Breast abscess

Background

Can occur in both lactating and nonlactating If breastfeeding, typically starts as mastitis and progresses to abscess Types of nonlactational (central, peripheral or skin)

• Central - periductal mastitis
• Peripheral - less common (DM, RA, trauma, steroids)
• Skin

Pathogens: staphylococcus aureus (MRSA incidence increasing), enterococci, bacteroides, strep pyogenes

Clinical Features

• Erythema
• Warmth
• Tenderness
• Fluctuant localized mass
• +/- Fever
• Risk factors: smoking, obesity

Differential Diagnosis

• Mastitis
• Cellulitis
• Malignancy (i.e inflammatory breast cancer)
• Clogged duct
• Galactocele

Evaluation

Workup

• Blood cultures if septic

Diagnosis

• Clinical diagnosis
• POCUS to evaluate for fluid pocket vs cellulitic changes OR formal US
• Formal breast US if malignancy concern

Management

Drainage: Needle aspiration

• Safe in the ED if no signs of necrosis/ ischemic skin
• Anesthetize with lidocaine 1% with epi
• Can use 18g needle to aspirate
• Send aspirate for culture to tailor antibiotics

Surgical

• Failure to respond to I&D in the ED
• Signs of skin ischemia/ necrosis or complex abscess
• Non responsive to antibiotics

Antibiotics

Outpatient

No MRSA risk factors:

• Dicloxacillin 500mg QID OR
• Cephalexin 500mg QID OR
• beta lactam allergy: Clindamycin 300-450mg TID

MRSA risk

• Trimethoprim-sulfamethoxazole DS 1-2 tabs BID
• Clindamycin 300-450mg TID

Inpatient - Vancomycin IVPB

Needs follow up in 2-3 days for wound check (sometimes needs to be re-drained) Referral to breast specialist (breast surgeon)

Harbor UCLA breast abscess pathway

References

Dixon, J Michael. “Primary Breast Abscess.” UpToDate, 11 Dec. 2024, www.uptodate.com/contents/primary-breast-abscess. Losifescu, Sarah. “Mastitis and Breast Abscesses.” emDocs, 5 Aug. 2020, www.emdocs.net/mastitis-and-breast-abscesses/.