Breast Abscesses and Masses Medication

Updated: Mar 08, 2019
  • Author: Andrew C Miller, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity, prevent complications and eradicate the infection.

Empiric therapy should have activity against S aureus, a common pathogen of primary breast abscess. Other pathogens may include methicillin-resistant S aureus (MRSA), Streptococcus pyogenes, E coli, Bacteroides species, Corynebacterium species, coagulase-negative staphylococci, Pseudomonasaeruginosa, Proteusmirabilis, and anaerobes. Therapy should be tailored to results of cultures and susceptibilities, if applicable.

Recurrent breast abscesses have an increased risk for mixed flora and anaerobic pathogens.

Antibiotics should be continued for 10-14 days.

Outpatient therapy for non-severe infection without MRSA risk: dicloxacillin or cephalexin or amoxicillin-clavulanate

Outpatient therapy in patients with hypersensitivity to beta-lactams: clarithromycin or doxycycline

Outpatient therapy for non-severe infection with MRSA risk: trimethoprim-sulfamethoxazole or clindamycin. Trimethoprim-sulfamethoxazole may be associated with an increased risk of allergic reactions relative to other MRSA-directed therapies. [80, 81]

Inpatient therapy for severe infection without risk of MRSA: nafcillin or oxacillin or ampicillin-sulbactam

Inpatient therapy for severe infection with risk of MRSA or in patients with beta-lactam allergy: clindamycin or vancomycin or linezolid or tigecycline or daptomycin

Emerging therapies include ceftaroline or dalbavancin or delafloxacin or oritavancin. These drugs have been approved by the FDA for treatment of soft-tissue infections but have not yet been studied specifically for treating breast infections.

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Antibiotics

Class Summary

Antibacterial therapy must cover all likely pathogens in the context of the clinical setting.

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Penicillins

Dicloxacillin

Outpatient therapy

Drug of choice (DOC) for mastitis. Bactericidal antibiotic that inhibits cell wall synthesis. Used to treat infections caused by penicillinase-­producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Amoxicillin/clavulanate (Augmentin, Augmentin ES-600, Augmentin XR)

Outpatient therapy

Amoxicillin binds to penicillin­-binding proteins, thus inhibiting final transpeptidation step of peptidoglycan synthesis in bacterial cell walls; addition of clavulanate inhibits beta-­lactamase–producing bacteria, allowing amoxicillin extended spectrum of action

It is a semisynthetic antibiotic with a broad spectrum of bactericidal activity, covering both gram-­negative and gram-­positive microorganisms.

Nafcillin

Inpatient therapy

DOC for puerperal breast abscess. Used to treat infections caused by penicillinase-­producing staphylococci. Used to initiate therapy when a penicillin G–resistant staphylococcal infection is suspected.

Because of occasional occurrence of thrombophlebitis associated with parenteral route (particularly in elderly persons), administer parenterally only for a short term (24-­48 hours) and change to a PO equivalent, if clinically possible.

Oxacillin (Bactocill)

Inpatient therapy

Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by penicillinase­-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Ampicillin/sulbactam (Unasyn)

Inpatient therapy

Alternative DOC for nonpuerperal breast abscess. Drug combination that utilizes a beta-­lactamase inhibitor with ampicillin.

Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

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Cephalosporins, 1st Generation

Cephalexin (Keflex, Daxbia)

Outpatient therapy

Cephalexin is a first-generation cephalosporin that binds to penicillin-binding proteins, therefore inhibiting bacterial cell wall synthesis. May be used to initiate therapy when a staphylococcal infection is suspected. Lacks coverage of gram-negative pathogens.

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Cephalosporins, 4th Generation

Ceftaroline (Teflaro)

Emerging therapy

Beta­-lactam cephalosporin with activity against aerobic and anaerobic gram-­positive and aerobic gram-­negative bacteria.

Demonstrates activity in vivo against resistant MRSA strains and in vitro against vancomycin-­resistant and linezolid­-resistant S aureus.

Pregnancy Category B, effects unknown. Unknown if secreted in breast milk; use caution if breastfeeding.

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Fluoroquinolones

Delafloxacin (Baxdela)

Emerging treatment

Fluoroquinolone antibiotic that inhibits enzymes required for bacterial synthesis.

In vitro activity against S aureus (including MRSA), Streptococcus species, E coli, K pneumoniae, E cloacae, and P aeruginosa.

Limited data regarding use in pregnancy and lactation.

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Glycopeptides

Vancomycin

Inpatient treatment

DOC for patients with puerperal breast abscess who are penicillin-allergic, as well as those with suspected MRSA infection. It is a potent antibiotic directed against gram­-positive organisms and active against enterococcal species. Useful in treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or who have infections with resistant staphylococci.

To avoid toxicity, current recommendation is to assay vancomycin trough levels after the third dose drawn 0.5 hour before next dosing. Use CrCl to adjust dose in renal impairment, prn.

Caution: Vancomycin can cross the placenta and into breast milk. Use caution in pregnant and breastfeeding mothers.

Dalbavancin (Dalvance)

Emerging treatment

Lipoglycopeptide antibiotic; interferes with cell wall synthesis by binding to D-alanyl-D-alanine terminus of the stem pentapeptide in nascent cell wall peptidoglycan, thus preventing cross­linking.

Bactericidal in vitro against S aureus and S pyogenes at concentrations observed in humans at recommended doses.

Caution: Pregnancy category C, the long half-­life of dalbavancin should be considered before using in pregnancy. Unknown if secreted in breast milk.

Oritavancin (Orbactiv)

Emerging treatment

Lipoglycopeptide antibiotic; interferes with bacteria cell wall synthesis by inhibiting transglycosidation and transpeptidation. Also disrupts the integrity of bacterial membranes, leading to cell death.

Exhibits concentration-dependent bactericidal activity against S aureus (including MRSA), Streptococcus species, and Enterococcus faecalis (not VRE).

Caution: Pregnancy category C. Unknown if distributed in human breast milk.

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Glycylcyclines

Tigecycline (Tygacil)

Inpatient treatment

If MRSA risk with beta-lactam allergy.

A glycylcycline antibiotic that is structurally similar to tetracycline antibiotics; inhibits bacterial protein translation by binding to 30S ribosomal subunit and blocks entry of amino­acyl tRNA molecules in ribosome A site.

Caution: Pregnancy Category D. Unknown, but suspected to be secreted in breast milk; do not use in pregnancy or if breastfeeding.

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Oxazolidinones

Linezolid (Zyvox)

Inpatient or outpatient treatment

If MRSA risk with beta-lactam allergy.

Binds to bacterial 23S rRNA of the 50S subunit to prevent protein translation; also elicits nonselective MAO inhibition.

Caution: Pregnancy category C; secreted in breast milk, use caution if used while breastfeeding.

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Lincosamide

Clindamycin (Cleocin)

Outpatient or inpatient therapy

Clindamycin is a semisynthetic antibiotic produced by 7(S)-chloro-substitution of the 7(R)-hydroxyl group of the parent compound, lincomycin. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Clindamycin is widely distributed in the body without penetrating the central nervous system (CNS). It is protein-bound and excreted by the liver and kidneys.

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Lipopeptides

Daptomycin (Cubicin)

Inpatient treatment

If MRSA risk with beta-lactam allergy.

Cyclic lipopeptide: Binds to bacterial membranes and causes rapid depolarization of membrane potential; causes inhibition of protein, DNA, RNA synthesis, and bacterial cell death.

Pregnancy category B, successful use during second and third trimesters of pregnancy reported but limited information available. Secreted in breast milk in low concentrations, however, it is poorly bioavailable orally; use caution if breastfeeding.

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Sulfonamides

Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS)

Outpatient therapy

For non-severe MRSA infections.

Trimethoprim: Inhibits dihydrofolate reductase, thereby blocking production of tetrahydrofolic acid from dihydrofolic acid.

Sulfamethoxazole: Inhibits bacterial synthesis of dihydrofolic acid by competing with para­aminobenzoic acid.

Caution: Pregnancy category D. Medication crosses into breast milk. Avoid use in breastfeeding mother if nursing preterm infants, infants <2 months, or children with known or suspected glucose-6-phosphate dehydrogenase (G6PD) deficiency.

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Tetracyclines

Doxycycline (Acticlate, Adoxa, Doryx, Morgidox, Vibramycin)

Outpatient or inpatient therapy

If beta-lactam hypersensitivity.

Doxycycline is a tetracycline. Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria; may block dissociation of peptidyl t­RNA from ribosomes, causing RNA-­dependent protein synthesis to arrest.

Caution: Pregnancy Category D and secreted in breast milk; do not use in pregnancy or if breastfeeding.

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