Breast Abscess

Breast Abscess: Excerpt from The 5-Minute Pediatric Consult

Charles A. Pohl, MD

Breast Abscess - BASICS

Breast Abscess - description

• Breast abscess: Infection of the breast bud or tissue associated with localized pus and inflammation
• Mastitis: Infection of the breast tissue observed primarily during lactation

Breast Abscess - general prevention

• Avoid breast manipulation (including piercing).
• In lactating teens, establish good breast-feeding techniques.
• Recognize and treat mastitis early.

Breast Abscess - epidemiology

Breast Abscess - incidence

5–11% of women with breast-feeding mastitis develop a breast abscess.

Breast Abscess - prevalence

• Affects primarily infants (peak age 1–6 weeks) and adolescents
• Bilateral abscesses, seen among neonates, are rare.
• Male-to-female ratio is 1:2 in neonates.

Breast Abscess - risk factors

• In lactating teens, primiparity
• Gestational age >40 weeks
• Mastitis

Breast Abscess - pathophysiology

• Newborns:
  • Trauma, breast hypertrophy from maternal estrogen, or compromised host defenses enable spread of bacteria that are often colonized in the nasopharynx and umbilicus.
  • The bacteria and/or its toxin, in turn, cause(s) subcutaneous destruction and loculated pus formation.
• Adolescents/adults: Trauma (e.g., sexual manipulation, nipple rings, tight-fitting bras, incorrect latching during breast-feeding), contiguous spread of a local infection (e.g., mastitis, acne), or underlying structural abnormalities (e.g., mammary duct ectasia, epidermal cysts) cause breast tissue edema and destruction by bacteria and/or its toxin.
• When mastitis is associated with breast-feeding, the inflammation inhibits milk release. The stasis of milk, in turn, may allow for bacterial proliferation.

Breast Abscess - etiology

• Newborn infection: Staphylococcus aureus (most common), group A or B streptococcus, and Gram-negative enteric bacteria, including Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis, salmonella species
• Adolescent/adult infection: Staphylococcus aureus (most common); Escherichia coli, Pseudomonas aeruginosa, Mycobacterium tuberculosis, Neisseria gonorrhoeae, and Treponema pallidum are infrequent pathogens.

Breast Abscess - DIAGNOSIS

Breast Abscess - signs & symptoms

Breast Abscess - history

• Ask about history of breast trauma or manipulation, concomitant illness or infections, and patient’s immunologic status.
• Constitutional symptoms including irritability and lethargy usually are absent unless the infection involves deeper tissue or the bloodstream (1/3 of cases).
• Low-grade fever
• Salmonella infections present with gastrointestinal symptoms.

Breast Abscess - physical exam

• Firm, tender breast mass with overlying erythema and warmth. Fluctuant mass may be present.
• Regional adenopathy
• Purulent nipple discharge (rare)
• Necrotizing fasciitis is distinguished from breast abscess by pain out of proportion of cutaneous signs, crepitation, or presence of straw-colored bullae.

Breast Abscess - tests

Breast Abscess - lab

• Gram stain and culture of nipple discharge, needle aspirate, and/or surgical incision and drainage help(s) guide therapeutic decisions if a fluctuant mass or discharge is present.
• Blood culture:
  • Useful in neonates
  • Consider full sepsis workup if patient is febrile and toxic-appearing.
• CBC: Leukocytosis (>15,000 cells/mm³) is present in 1/2–2/3 of patients.
• Surveillance cultures of nasopharynx and umbilicus should be considered in neonates to rule out colonization with Staphylococcus aureus.

Breast Abscess - imaging

Ultrasound may be useful if fluctuant mass is suspected or if poor response to antimicrobial therapy.

Breast Abscess - diag proced-surgery

If fluctuant, needle biopsy may be diagnostic and therapeutic.

Breast Abscess - differencial diagnosis

• Physiologic conditions:
  • Breast engorgement (usually bilateral; absence of fever and erythema)
  • Mastodynia (painful breast engorgement; associated with ovulatory cycles; cyclic pattern)
• Infectious: Cellulitis including mastitis (absence of a loculated breast mass)
• Tumors (rare):
  • Fibroadenomas
  • Rhabdomyosarcoma
  • Non-Hodgkin lymphoma
  • Fibrocystic disease
  • Intraductal papilloma
  • Cystosarcoma phyllodes
  • Hemangioma
• Trauma:
  • Contusion (firm, tender, poorly defined mass)
  • Hematoma (sharply defined mass with ecchymosis)
  • Fat necrosis (firm, nontender, circumscribed, mobile mass)
• Miscellaneous: Mondor disease:
  • Thrombophlebitis of the subcutaneous veins in the breast
  • Presents with tenderness and pain
  • Associated with trauma
  • Spontaneously resolves
• Vascular malformation

• Neonatal infections require prompt recognition, intervention, and identification of other involved sites to avoid widespread infection and poor outcome.
• Unrecognized fluctuant mass and its subsequent drainage will delay therapeutic response.
• Incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is increasing in many regions of the country.

Breast Abscess - TREATMENT

Breast Abscess - general measures

• Warm compresses
• Analgesics (e.g., nonsteroidal anti-inflammatory agent) help control the inflammation and pain in older children.
• Continuation of breast-milk expression helps prevent engorgement and further milk stasis.

Breast Abscess - activity

Limited only by pain and malaise.

Breast Abscess - medication

• Neonatal infection:
  • Parenteral β-lactamase-resistant antistaphylococcal antibiotics (e.g., ceftriaxone 50–75 mg/kg/24h)
  • Aminoglycosides (e.g., gentamicin 2.5 mg/kg/dose q8–12h) should be included if the infant appears ill or if the Gram stain reveals Gram-negative bacilli.
• Adolescent infection:
  • Parenteral antistaphylococcal antibiotics (e.g., nafcillin 50–100 mg/kg/24h; maximum 12 g/24h)
  • Consider clindamycin (450–1,800 mg/24h orally with max dose 1.8 g/24h; 1,200–1,800 mg/24h parenterally with max dose 4.8 g/24h) in patients with penicillin allergies.
  • Consider adding aminoglycosides in situations as described above.
• Duration:
  • Usually for 10–14 days
  • Length of parenteral treatment is based on isolate and the clinical response. Oral agents may be used after a few days if a good clinical response occurs.

Breast Abscess - surgery

• Incision and drainage if a fluctuant mass is present
• Surgical exploration is necessary if necrotizing fasciitis is suspected.

Breast Abscess - FOLLOW UP

Clinical improvement should be evident after 48 hours of parenteral antibiotics.

Signs to watch for:

• A poor or delayed clinical response to antibiotic therapy suggests a resistant organism, an unusual pathogen, or a different diagnosis.
• An evolving fluctuant mass warrants surgical intervention.
• Reaccumulation of fluctuant mass
• Toxic appearance, prolonged fever, purulent discharge, or progressive erythema postoperatively
• Crepitation associated with excessive pain and/or straw-colored bullae suggests necrotizing fasciitis.

Breast Abscess - disposition

Breast Abscess - admission criteria

• Ill appearance
• Neonates
• Inability to tolerate oral medications
• Concern for medication nonadherence

Breast Abscess - discharge criteria

Based on clinical response to medication

Breast Abscess - issues for referral

Consider referral to an infectious disease specialist if recurrent.

Breast Abscess - prognosis

• Most children recover without any sequelae.
• Neonates are more likely to have bilateral abscesses (<5% cases).
• Neonates have higher morbidity and complications.

Breast Abscess - complications

• Cellulitis (most common; 5–10%)
• Abscess rupture with disseminated infection (e.g., bacteremia, pneumonia)
• Septicemia
• Toxin syndromes (e.g., toxic shock syndrome)
• Necrotizing fasciitis
• Scar formation from mammary gland destruction (associated with a reduced breast size after puberty)

Breast Abscess - bibliography

1. Barbosa-Cesnik C, Schwartz K, Foxman B. Lactation mastitis. JAMA. 2003;289:1609–1612.
2. Bodemer C, Panhans A, Chretien-Marquet B, et al. Staphylococcal necrotizing fasciitis in the mammary region in childhood: A report of five cases. J Pediatr. 1997;131:466–469.
3. Foxman B, D’Arcy H, Gillespie B, et al. Lactation mastitis: Occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002;155:103–114.
4. Michie C, Lockie F, Lynn W. The challenge of mastitis. Arch Dis Child. 2003;88:818–821.

Breast Abscess - CODES

Breast Abscess - icd9

• 611.0 Breast (acute) (chronic) (nonpuerperal)
• 771.5 Newborn
• 675.1 Puerperal, postpartum

Breast Abscess - PATIENT TEACHING-MED

• Continue breast-feeding.
• Establish good breast-feeding techniques.

Breast Abscess - FAQ

• Q: How can you differentiate a breast abscess from mastitis?
• A: Although both illnesses involve signs of inflammation (i.e., warmth, erythema, swelling, tenderness), a breast abscess is distinguished from mastitis in that the former presents as a firm, well-defined mass (with or without fluctuant material).
• Q: Should a mother discontinue breast-feeding if she has a breast abscess?
• A: To avoid milk stasis, breast-feeding should be continued unless impeded by a surgical incision site or the overall clinical condition of the mother.
• Q: What is the role of homeopathic remedies (e.g., belladonna, Phytolacca) in the treatment of mastitis and breast abscess?
• A: Currently, there is insufficient scientific evidence to support their routine use.
• Q: Are anaerobic organisms common pathogens for breast abscesses?
• A: No. Although anaerobic pathogens are isolated in up to 40% of infections, their role is controversial and therapy directed at them is unnecessary.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Breast abscess

• Back to disease: Breast abscess: Introduction
• Next Book Extract About Breast abscess: Surveys relating to Breast abscess
• More Book Extracts: All Online Books for Breast abscess

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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