Breast Abscesses and Masses Treatment & Management

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

Emergency Department Care

Breast mass

Definitive diagnosis of the etiology can only be made by pathologic examination and is not an emergency. Timely follow-up care, including mammography and involvement of primary physician and surgeon, is essential.

Finding a breast mass can be stressful for patients; provide reassurance that not all breast masses are malignant.

Mastitis

For detailed therapy, see Mastitis Empiric Therapy and Mastitis Organism-Specific Therapy.

In general, mastitis is treated with antibiotic therapy for 10-14 days, warm or cold compresses, and continued breast emptying via breastfeeding or breast pumping every 2 hours or when engorged.

Antibiotic therapy with continued breast emptying has been shown to be superior to breast emptying alone for resolving symptoms, decreasing recurrence rate, and decreasing the risk of abscess development. [1, 9] The addition of appropriate antibiotic administration may relieve symptoms in 2.1 days, as compared with 4.2 days for supportive care or 6.7 days if no action is taken. [9] In breastfeeding mothers, use beta-lactamase stable penicillin. Other choices include dicloxacillin 500 mg orally 4 times daily or cephalexin 500 mg orally 4 times daily for 10-14 days. Instruct patients who are lactating that continued breastfeeding from the affected breast is not harmful to the baby. For nonpuerperal mastitis, use clindamycin 600 mg intravenously every 8 hours or 300 mg orally every 6 hours, or amoxicillin/clavulanate 500 mg orally 3 times daily. [67] If a breast abscess is suspected in a nursing mother, the affected breast should not be used to nurse the baby owing to the risk of passing infection to the baby. [4]

Breast abscess

Historically, incision and drainage was considered the standard of care for abscesses. Although this method yields a lower reoccurrence rate, it is more invasive than needle aspiration and frequently results in scarring with structural damage and poor cosmetic outcomes. [58] Fine-needle aspiration should be considered first-line therapy for abscesses smaller than 5 cm owing to its lower risks, followed by incision and drainage if recurrence occurs. [4] Although success has been reported with oral antistaphylococcal antibiotics and serial aspiration, [68] surgical excision may be required for infected or obstructed lactiferous ducts and provides a lower rate of recurrence for nonpuerperal abscess and mastitis. [59, 8]

For persistent lesions, treatment options may include ultrasound-guided needle aspiration, [20] percutaneous drainage catheter, [66, 66] and/or surgical drainage. Ultrasound-guided needle aspirations are more successful for abscesses smaller than 3 cm and for puerperal abscesses. [60, 61, 62, 8, 69] Loculations are associated with failure of resolution with aspiration, regardless of abscess volume. [63] Nonpuerperal abscesses have a higher recurrence rate and often require multiple drainage attempts. [8] Regardless of the underlying organism, the need for repeat aspiration is common in patients treated with aspiration versus incision and drainage. [64] In a US cohort of 54 abscess cases treated with needle-guided aspiration, the median number of drainage procedures was 2 (interquartile range, 1.0-4.0), with 24% requiring 5 or more drainage procedures. [37]

Vacuum-assisted biopsy is a viable option for the management of lactational breast abscesses and has been associated with a shorter healing time than simple needle aspiration. [65] ​ Furthermore, percutaneous catheter drainage may be considered for larger abscesses. [4, 66]

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Consultations

Patients with breast masses require a general surgeon for definitive treatment. Immediate consultation in the ED is not mandatory, but it may help facilitate faster follow-up care once patients are discharged from the hospital.

Patients with mastitis unresolved by a single course of correct antibiotics need urgent referral to a surgical breast specialist. [11] Similarly, refer patients with breast abscesses for surveillance of complications and possible recurrent breast abscesses.

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Long-Term Monitoring

Breast mass screening

For breast cancer screening guidelines, see the Guidelines section.

Future studies are needed to determine the efficacy and effectiveness of breast cancer screening with mammography in women aged 40-49 years. Some research shows a modest decrease in breast cancer mortality when women in this age group are screened; however, further research is needed to compare risks of overdiagnosis (one study suggests 1 in 424 women screened would be overdiagnosed) versus potential benefits of screening. [29, 70]

Similar rates of cancer detection have been found between short-term interval follow-up (SIFU) and return to annual screening (RTAS) after benign breast biopsy with no significant differences in stage, tumor size, or nodal status, although the present study was limited by sample size. [71] Additionally, positive predictive values have been reported not to change in patients receiving 6 and 12-month re-biopsy follow-up. [72] These findings suggest that patients with benign radiologic-pathologic-concordant percutaneous breast biopsy results could return to annual screening.

Mastitis

In addition to therapeutic breast emptying (if indicated), antibiotic therapy, and warm or cold compresses, emerging evidence suggests that therapeutic administration of lactobacilli strains that are naturally occurring in breast milk may be of therapeutic benefit for the management of infectious mastitis during lactation. [73, 9]

Mastitis that is refractory to standard treatment (see above) should prompt further workup to rule out uncommon infectious etiologies, granulomatous diseases, and/or idiopathic causes. [12]

Recurrent periductal mastitis may require combined total excision of the affected duct and the fistulous tract with encouraged smoking cessation (if applicable). [74]

Treatment of idiopathic granulomatous mastitis usually involves corticosteroids and methotrexate, with or without surgery.

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Further Inpatient Care

Consider admitting patients with large or complex breast abscesses for pain management, parenteral antibiotic therapy, and definitive management. Admit patients with sepsis due to mastitis. Consider diabetic ketoacidosis in patients with nonpuerperal breast abscess.

Treatment may include incision and drainage, fine-needle aspiration, vacuum-assisted aspiration, and fistulectomy in the operating room. The wound can be left to close by secondary intention or with simple sutures over a drain. [75, 4] Cultures of the drained fluid should be obtained at this time and sent to determine antimicrobial susceptibility. [4]

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Inpatient and Outpatient Medications

Prescribe pain medication to patients with a breast abscess as necessary. NSAIDs, such as ibuprofen, are preferred because they are not transferred through breastmilk. Preparations combining acetaminophen with codeine, oxycodone, or hydrocodone may be used depending on the level of discomfort but should be avoided in breastfeeding mothers with concern for sedation and respiratory depression in the infant.

Prescribe parenteral narcotics for pain control while awaiting definitive surgical therapy.

Continue antibiotic therapy for 14 days after drainage.

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Transfer

Transfer typically is not necessary for patients with breast mass, abscess, or mastitis.

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