Breast abscesses in lactating women: evidences for ultrasound-guided percutaneous drainage to avoid surgery

A Comparative Study of Drainage of Breast Abscesses by Conventional Incision and Drainage vs Ultrasound-Guided Needle Aspiration/Re-Aspiration in A Tertiary Health Care Centre

OBJECTIVE

Breast abscesses are localized purulent collections, often arising from bacterial mastitis, and pose significant health risks, especially for lactating women. The aim of this study was to compare the efficacy and outcomes of two different treatment approaches: Traditional incision and drainage (I&D) versus ultrasound (USG)-guided aspiration in breast abscess management.

MATERIALS AND METHODS

Fifty female patients with breast abscesses were enrolled and divided into two groups: Group A (n = 25, I&D) and group B (n = 25, USG-guided aspiration). Group A underwent I&D under general anaesthesia and group B underwent USG-guided aspiration under local anaesthesia. The patients were followed up for two weeks after the procedure. Patient demographics, abscess characteristics, treatment outcomes, and complications were analyzed.

RESULTS

The mean age of patients was 36.4 and 31.8 in group A and B, respectively and the mean abscess size was 5.7 cm. The study found that USG-guided aspiration was associated with several advantages over I&D. Patients in group B experienced shorter healing times (5 days vs. 13 days, p = 0.001), lower rates of residual abscesses (12% vs. 36%, p = 0.047), and no recurrence after two weeks vs. 28% in group A (p = 0.012). Notably, the resumption of lactation was significantly greater in group B (91.67% vs. 20%). Importantly, patients in group B had no scarring, while 37% in group A healed with scars.

CONCLUSION

These results highlight that USG-guided aspiration offers a minimally invasive and effective method for managing breast abscesses, leading to quicker recovery, better cosmetic outcomes, and higher patient satisfaction compared to the traditional I&D approach. Early diagnosis and intervention with USG-guided aspiration can prevent complications and reduce the need for open surgery. Based on these findings, USG-guided aspiration is a safer and more efficient method for treating breast abscesses, particularly when initiated promptly after diagnosis.

Mastitis and Mammary Abscess Management Audit (MAMMA) in the UK and Ireland

BACKGROUND

The aim of this multicentre prospective audit was to describe the current practice in the management of mastitis and breast abscesses in the UK and Ireland, with a specific focus on rates of surgical intervention.

METHODS

This audit was conducted in two phases from August 2020 to August 2021; a phase 1 practice survey and a phase 2 prospective audit. Primary outcome measurements for phase 2 included patient management pathway characteristics and treatment type (medical/radiological/surgical).

RESULTS

A total of 69 hospitals participated in phase 2 (1312 patients). The key findings were a high overall rate of incision and drainage (21.0 per cent) and a lower than anticipated proportion of ultrasound-guided aspiration of breast abscesses (61.0 per cent). Significant variations were observed regarding the rate of incision and drainage (range 0-100 per cent; P < 0.001) and the rate of needle aspiration (range 12.5-100 per cent; P < 0.001) between individual units. Overall, 22.5 per cent of patients were admitted for inpatient treatment, out of whom which 72.9 per cent were commenced on intravenous antibiotics. The odds of undergoing incision and drainage for a breast abscess or being admitted for inpatient treatment were significantly higher if patients presented at the weekend compared with a weekday (P ≤ 0.023). Breast specialists reviewed 40.9 per cent of all patients directly, despite the majority of patients (74.2 per cent) presenting within working hours on weekdays.

CONCLUSIONS

Variation in practice exists in the management of mastitis and breast abscesses, with high rates of incision and drainage in certain regions of the UK. There is an urgent need for a national best-practice toolbox to minimize practice variation and standardize patient care.

Percutaneouse ultrasound-guided needle aspiration for management of breast abscesses - a review

Breast abscesses are still a common cause of morbidity among lactational females. Over the years, there has been an increase in the incidence of non-lactational breast abscesses and a decrease in lactational breast abscesses. The management could be the use of the conventional method of surgical incision and drainage or the newer techniques of needle aspiration or suction drain or catheter in addition to the administration of antibiotics. The use of needle aspiration as the minimal-invasive conservative technique is generally recommended for abscesses less than 3-5 cm in diameter. However, recent studies have compared the two methods for abscesses larger than 3 cm and among patients with risk factors for breast abscesses. We aim to present the clinical evidence showing the comparison between needle aspiration and incision and drainage for breast abscesses irrespective of the size of the abscesses. There is a lack of comparative information on the two treatment modalities for breast abscesses larger than 3 cm in diameter; however, needle aspiration is being tried because of its advantages like cosmetic preference, short hospital stay and healing time, and no stoppage of breastfeeding.

Lactation breast abscess treated with Gualou Xiaoyong decoction and painless lactation manipulation: A case report and review of literature

BACKGROUND

Breast abscess during lactation is a severe complication of acute mastitis, which can lead to discomfort, high fever, breast fistula, sepsis, septic shock, breast damage, disease persistence and frequent hospitalization. Breast abscesses may also lead the mother to discontinue breastfeeding, thereby harming the infant’s health. The predominant pathogenic bacteria are Staphylococcus aureus, Staphylococcus epidermidis and Streptococcus. The incidence of breastfeeding abscesses in breastfeeding women ranges between 4.0% and 11.0%. In cases of breast abscess, the rate of cessation of lactation is 41.0%. In instances of breast fistula, the rate of cessation of lactation is very high (66.7%). Furthermore, 50.0% of women with breast abscesses must be hospitalized and treated with intravenous antibiotics. Treatment includes antibiotics, abscess puncture and surgical incision and drainage. The patients suffer from stress, pain and easily induced breast scarring; the disease’s progression is prolonged and recurrent, interfering with infant feeding. Consequently, it is crucial to discover an adequate cure.

CASE SUMMARY

A 28-year-old woman with a breast abscess was treated with Gualou Xiaoyong decoction and painless breast opening manipulation 24 d after cesarean delivery. On the 2^nd d of treatment, the patient’s breast mass was significantly reduced, the pain was significantly reduced, and the general asthenia was improved. All conscious symptoms disappeared after 3 d, breast abscesses faded after 12 d of treatment, inflammation images disappeared after 27 d, and normal lactation images were restored.

CONCLUSION

In treating breast abscesses during breastfeeding, the combination of Gualou Xiaoyong decoction and painless lactation provides a positive therapeutic impact. This disease’s treatment offers the advantages of a short course of treatment, no need to discontinue breastfeeding and the ability to rapidly mitigate symptoms, which can be used as a reference in clinical practice.

Application of arthroscopic system in the treatment of lactational breast abscess

Purpose

Optimal treatment of breast abscesses has been controversial. Herein, we report an innovative method for the operative treatment of lactational mammary abscesses.

Methods

Nineteen lactating patients diagnosed with breast abscesses were enrolled in the study, and abscess debridement and drainage were performed using an arthroscopic system. The clinical characteristics of the patients were recorded to evaluate the feasibility, efficacy, and cosmetic results of arthroscopic surgery for breast abscesses.

Results

All 19 patients were cured and did not relapse within the 6-month-follow-up period. One patient stopped breastfeeding due to breast leakage. All patients were satisfied with the postoperative appearance of the breast.

Conclusion

Arthroscopic debridement and drainage are effective treatment methods for lactational breast abscesses, with a high cure rate, few complications, and satisfactory cosmetic outcomes.

Initiating and Supporting Breastfeeding: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Exclusive breastfeeding is recommended for children for the first 4 to 6 months of life, with complementary foods added thereafter. It is the most ecological way of protecting the child's and mother's health. Training of health professionals is required to avoid transmitting inconsistent information in 3 areas: 1) implementing these 3 predictors: safe skin-to-skin, first breastfeed, and rooming-in 24/7; 2) teaching and monitoring: i) early signs of waking and feeding rhythms, ii) positioning and latching, and iii) signs of effective transfer; and 3) referring women to specialized support services if difficulties arise (eg, inadequate milk production, pain, cracked nipples, engorgement). Breastfeeding should continue during mastitis or an abscess. Ultrasound-guided needle aspiration is beneficial in treating an abscess. Précis: Information is provided to enable health professionals to better support breastfeeding and help women with the most common difficulties, thus promoting breastfeeding initiation and duration.

Management of Breast Abscess during Breastfeeding

(1) Background: Breast abscess (BA) is a condition leading in the majority of cases to breastfeeding interruption. Abscesses are commonly treated with antibiotics, needle aspiration or incision and drainage (I&D), but there is still no consensus on the optimal treatment. Since there are no well-defined clinical guidelines for abscess management, we conducted a retrospective, observational study with the aim of assessing ultrasound (US)-guided management of BA without surgery, regardless of the BA size. The secondary objective was the microbiologic characterization and, in particular, the S. aureus methicillin resistance identification. (2) Methods: our population included 64 breastfeeding mothers with diagnosis of BA. For every patient, data about maternal, perinatal and breastfeeding features were collected. All patients underwent office US scans and 40 out of 64 required a more detailed breast diagnostic ultrasound performed by a radiologist. In all cases, samples of milk or abscess material were microbiologically tested. All patients received oral antibiotic treatment. We performed needle aspiration, when feasible, even on abscesses greater than 5 cm. (3) Results: most of the women developed BA during the first 100 days (68.8% during the first 60 days) after delivery and 13 needed hospitalization. Four abscesses were bilateral and 16 had a US major diameter greater than 5 cm. All patients were treated with antibiotic therapy according to our clinical protocol and 71.9% (46/64) underwent fine needle aspiration. None of them required I&D. The average duration of breastfeeding was 5 months (IR 2; 9.5) and 40.6% of women with BA continued to breastfeed for more than 6 months. Only 21 mothers interrupted breastfeeding before 3 months. (4) Conclusions: our observational data suggest, regardless of the size and the clinical features of the BA, a conservative approach with antibiotic therapy targeted at the Methicillin-Resistant Staphilococcus aureus (MRSA) identified and needle aspiration, if feasible. In our experience, treatment with needle aspiration is a cost- effective method. Unlike drainage, it is an outpatient procedure, easily repeatable, with no cosmetic damage. In addition, it has lower risk of recurrences since, differently from surgical incision, it does not cause interruption of the ducts. Moreover, needle aspiration is less painful, does not require the separation of the mother-child dyad and allows for a quicker, if not immediate, return to breastfeeding.

Unconventional Treatment of Breast Abscess: Case Report

We describe the case of two lactating mothers with breast abscesses who refused invasive interventions. In the first case, a mother developed a 10 mm abscess and refused needle aspiration. Under ultrasonography (US) follow-up she was treated with antibiotics until the abscess disappeared on the US scan, while fully breastfeeding. In the second case, a woman with a large abscess refused invasive interventions. We followed the recommendations in case of breast Adenitis, first to nurse the baby from the affected breast and then squeezing regularly the lump to drain the pus. In this study, we demonstrate that this procedure is also beneficial in the case of breast abscesses. Under antibiotic treatment, the abscess was completely resolved on the US scan after 23 days. In conclusion, when invasive intervention is refused in the case of breast abscess, successful treatment can be applied by using effective breast drainage, US follow-up, and aggressive antibiotic therapy.

Risk Factors for Failure of Ultrasound-Guided Fine-Needle Aspiration Therapy for Lactational Breast Abscess

Background: Ultrasound-guided fine-needle aspiration in the treatment of breast abscess has become the preferred treatment. Although fine-needle aspiration has a good therapeutic effect, there are still some patients failed who finally underwent drainage. Objective: To analyze the risk factors of ultrasound-guided fine-needle aspiration treatment failure for patients with lactational breast abscess. Materials and Methods: The clinical data of 1,472 patients with lactational breast abscess who underwent ultrasound-guided fine-needle aspiration treatment from January 2014 to March 2017 were analyzed in this retrospective study. According to the treatment results, these patients were divided into two groups: fine-needle aspiration failure group (n = 111) and fine-needle aspiration recovery group (n = 1,361). Chi-square test was used to compare the differences between the two groups in terms of postpartum time, age, location of abscess cavity, number of abscess cavities, volume of pus, frequency of aspiration, infected bacteria, treatment time, weaning, and recurrence. Multivariate logistic regression was used to analyze the risk factors of patients with failed fine-needle aspiration treatment. Results: Univariate analysis showed statistically significant differences in the location of abscess, volume of pus, treatment time, frequency of aspiration, and weaning between the two groups (p < 0.05). Multivariate analysis showed that the location of abscess, volume of pus, frequency of aspiration, and treatment time were risk factors for the failure of ultrasound-guided fine-needle aspiration treatment (p < 0.05). Conclusions: For patients with breast abscess during lactation, abscess in center area, volume of pus >50 mL, frequency of aspiration >3 times and treatment time >14 days, the failure probability of ultrasound-guided fine-needle aspiration treatment was high. Therefore, whether fine-needle aspiration is the preferred treatment for these patients needs to be considered.

Clinical characteristics of lactational breast abscess caused by methicillin-resistant Staphylococcus aureus: hospital-based study in China

Background

This study aimed to identify the differences in clinical characteristics, puncture efficacy, antibiotic use, treatment duration, breastfeeding post-illness, and recurrence of patients with breast abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-susceptible Staphylococcus aureus (MSSA) infection during lactation.

Methods

The clinical data of patients with breast abscesses during lactation who were treated from January 2014 to February 2017 at Haidian Maternal and Child Health Hospital, Beijing, were reviewed. According to bacterial culture results, they were divided into MRSA (n = 260) and MSSA (n = 962) groups. Hospitalization (whether or not the patients were hospitalized), postpartum period, maternal age, location of abscess cavities, number of abscess cavities, amount of pus, frequency of needle aspiration, failure of needle aspiration, antibiotic use, treatment duration, cessation of breastfeeding and recurrence were compared between the two groups using a t-test and a chi-squared test.

Results

We noted that only the cessation of breastfeeding was statistically significantly different between the two groups (P = 0.018). Hospitalization, postpartum period, maternal age, location of abscess cavities, number of abscess cavities, amount of pus, number of needle aspiration, failure of needle aspiration, antibiotic use, treatment duration and recurrence showed no statistically significant differences (P = 0.488, P = 0.328, P = 0.494, P = 0.218, P = 0.088, P = 0.102, P = 0.712, P = 0.336, P = 0.512, P = 0.386 and P = 0.359, respectively).

Conclusions

There was no difference in clinical characteristics between breast abscesses infected by MRSA and those infected by MSSA. Ultrasound-guided needle aspiration could be the first choice for MRSA-infected breast abscess treatment. There is no need to increase antibiotic use because of MRSA infection, unless it is necessary. The reason why more patients with MRSA infected breast abscesses terminated breastfeeding is unclear from this study.

Management of lactating breast abscesses by ultrasound-guided needle aspiration and continuation of breastfeeding: A pilot study

INTRODUCTION

Needle aspiration of breast abscesses during lactation are currently recommended as an alternative to surgery only for moderate forms. In case of breast abscess, many patients stop breastfeeding on the advice of a health professional. We reviewed our experience of treatment of lactating breast abscesses by ultrasound-guided aspiration and suggest an algorithm of their management. We also analyzed the continuation of breastfeeding of these patients after advices from trained teams.

MATERIEL AND METHODS

We conducted a retrospective study from April 2016 to April 2017, including 28 patients referred for a breast abscess during lactation at the Duroc Breast Imaging Center. A management by ultrasound-guided aspiration was proposed to each patient. We collected data about the breastfeeding between October 2018 and January 2019.

RESULTS

A single aspiration was sufficient in 64.3% of cases. The delay between the occurrence of the abscess and the indication for drainage was significantly higher for patients who have needed finally surgical drainage (p = 0,0031). There were no difference of size of abscesses between patients receiving needle aspiration alone and those who have undergone surgery (p = 0,97). All patients who had been managed by needle aspiration continued breastfeeding after the treatment and 40% of the patients were still breastfeeding at 6 months.

CONCLUSION

The management of lactating breast abscess by ultrasound-guided needle aspiration is an effective alternative to surgery. It appears to be effective regardless of the size of the abscess and is compatible with the continuation of breastfeeding. Our study has indeed shown that if they are well advised, the majority of patients continue breastfeeding so that it is essential that health professionals be better trained regarding the management of breastfeeding complications.

Mastitis and More: A Pictorial Review of the Red, Swollen, and Painful Breast

Clinically, acute mastitis presents as a red, swollen, and painful breast. Targeted ultrasound can be performed to evaluate the extent of infection and for an underlying abscess. Noncomplicated mastitis or a small fluid collection may respond to oral antibiotics without further intervention, but a larger or more complex abscess may require single or serial percutaneous aspiration. Breast infections, particularly those complicated by an abscess, can have a prolonged clinical course, and close follow-up is required. Since the clinical presentation and imaging features of acute infectious mastitis can overlap with other etiologies, such as inflammatory breast cancer and idiopathic granulomatous mastitis, a percutaneous biopsy may be indicated to accurately diagnose patients.

Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

BACKGROUND

Abscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.

OBJECTIVE

This review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.

DISCUSSION

Ultrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.

CONCLUSIONS

This review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.

Lactational Breast Abscesses Caused by Methicillin-Resistant or Methicillin-Sensitive Staphylococcus aureus Infection and Therapeutic Effect of Ultrasound-Guided Aspiration

Background and Objective: We investigated whether (1) there are any differences in lactational breast abscesses between patients from whom methicillin-resistant Staphylococcus aureus (MRSA) and those from whom methicillin-sensitive S. aureus (MSSA) were isolated from pus samples and (2) there are differences in the effects of ultrasound-guided aspiration. Materials and Methods: The clinical data of 171 patients with lactational breast abscesses treated by ultrasound-guided aspiration in Beijing from January to July 2018 were retrospectively analyzed. The patients were divided into MSSA infection (N = 132) and MRSA infection (N = 39) groups according to their bacterial culture results. Abscess cavity location, abscess cavity number, maximum abscess cavity size, antibiotic utilization rate, and cure rate were compared between the groups. Cure rate refers to the proportion of the total number of cases remaining after the elimination of failed cases. The number of ultrasound-guided aspiration procedures performed for healing between the two groups was also compared. Results: There were no significant differences in abscess cavity location, abscess cavity amount, and abscess cavity size between both groups. The antibiotic utilization rate of the two groups were 58.3% (MSSA, 77/132) and 69.2% (MRSA, 27/39), respectively, and there were no significant differences between both groups. The cure rates of ultrasound-guided aspiration of the two groups were 97.7% (MSSA, 129/132) and 92.3% (MRSA, 36/39), and there were no significant differences between both groups. There were also no significant differences in the median number of aspiration performed for cure between the MRSA infection group (median = 3, range = 1-10) and the MSSA infection group (median = 3, range = 1-14). Conclusion: Lactational breast abscesses are the same irrespective of the type of S. aureus infection. Treatment by ultrasound-guided aspiration for patients with MRSA infection can achieve the same effect as that for those with MSSA infection.

The estimated incidence of lactational breast abscess and description of its management by percutaneous aspiration at the Douala General Hospital, Cameroon

Background

Lactational breast abscesses are uncommon in the puerperium but when they do develop, delays in specialist referral may occur especially in resource low settings. There is a dearth of studies regarding lactational breast abscesses in Cameroon. We aimed to estimate the incidence of lactational breast abscess and describe its management by percutaneous aspiration at the Douala General Hospital, Cameroon.

Methods

We conducted an observational prospective study of 25 breastfeeding women at the Douala General Hospital from January 1, 2015, to October 31, 2015. Participants were consenting breastfeeding women who completed a baseline questionnaire after diagnosis of lactational breast abscesses and underwent percutaneous needle aspiration under local anaesthesia. Data were analyzed by using descriptive statistics.

Results

The estimated incidence of lactational breast abscesses was 0.74% (28/3792). The age range of babies at the onset of breast abscess was 4 to 35 weeks; mean 28.3 ± 10.85 weeks. Forty-four per cent of participants underwent three lactational abscess aspirations and in 24 to 28% of them, it took 8 to 9 days for the abscess to resolve. In 72% of participants, treatment was with needle aspiration plus flucloxacillin. Seventy-six per cent of participants continued breastfeeding after abscess treatment.

Conclusion

The estimated incidence of lactational breast abscess at the Douala General Hospital is 0.74%. Percutaneous needle aspiration under local anaesthesia is an effective treatment for superficial lactational breast abscesses in most cases with or without ultrasound guidance and should be recommended worldwide as first line treatment. Further research is needed to understand the outcome of local infiltration of antibiotics on the abscess cavity.

Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging

We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as "high-risk" or B3 lesions). Finally, seven frequently asked questions are answered.