Breast Abscesses: Evidence-based Algorithms for Diagnosis, Management, and Follow-up

Abstract

Radiologists who regularly perform breast ultrasonography will likely encounter patients with breast abscesses. Although the traditional approach of surgical incision and drainage is no longer the recommended treatment, there are no clear guidelines for management of this clinical condition. Breast abscesses that develop in the puerperal period generally have a better course than nonpuerperal abscesses, which tend to be associated with longer treatment times and a higher rate of recurrence. The available literature on treatment of breast abscesses is imperfect, with no clear consensus on drainage, antibiotic therapy, and follow-up. By synthesizing the data available from studies published in the past 20 years, an evidence-based algorithm for management of breast abscesses has been developed. The proposed algorithm is easy to follow and has been validated by a multidisciplinary team approach and applied successfully during the past 2 years. Breast abscesses are a challenging clinical condition, and radiologists have a pivotal role in evaluation and follow-up of these lesions.

Emergency management of puerperal breast abscess

“…According to recently published 2011 algorithm, a trial of ultrasound guided drainage is recommended for all fluid collections suggesting an abscess, regardless of size, which occur during the breastfeeding period, are caused by S. aureus, and lack a multiloculated structure. The greatest success is achieved with abscesses that are \3 cm in diameter [3,4]. Abscesses that are multiloculated or larger than 3 cm in diameter may fail ultrasound-guided drainage; thus, in such instances, early surgical evaluation for incision and drainage is strongly recommended [4].…”

“…The greatest success is achieved with abscesses that are \3 cm in diameter [3,4]. Abscesses that are multiloculated or larger than 3 cm in diameter may fail ultrasound-guided drainage; thus, in such instances, early surgical evaluation for incision and drainage is strongly recommended [4]. In addition to ultrasound-guided drainage, all suspected breast abscesses should be managed with antibiotics including cloxacillin 500 mg four times daily, clindamycin 300 mg four times daily, erythromycin 500 mg three times daily, or cefazolin 500 mg four times daily for a total of 7-10 days [4,5].…”

“…Abscesses that are multiloculated or larger than 3 cm in diameter may fail ultrasound-guided drainage; thus, in such instances, early surgical evaluation for incision and drainage is strongly recommended [4]. In addition to ultrasound-guided drainage, all suspected breast abscesses should be managed with antibiotics including cloxacillin 500 mg four times daily, clindamycin 300 mg four times daily, erythromycin 500 mg three times daily, or cefazolin 500 mg four times daily for a total of 7-10 days [4,5]. Breast feeding should be continued throughout the treatment period and only discontinued when using antibiotics that are contraindicated for newborns (ciprofloxacin, tetracycline, or chloramphenicol), or if surgical incision and drainage is completed [4,5].…”

“…In addition to ultrasound-guided drainage, all suspected breast abscesses should be managed with antibiotics including cloxacillin 500 mg four times daily, clindamycin 300 mg four times daily, erythromycin 500 mg three times daily, or cefazolin 500 mg four times daily for a total of 7-10 days [4,5]. Breast feeding should be continued throughout the treatment period and only discontinued when using antibiotics that are contraindicated for newborns (ciprofloxacin, tetracycline, or chloramphenicol), or if surgical incision and drainage is completed [4,5]. In the rare cases in which breast abscess is clinically suspected, but initial ultrasound fails to demonstrate a defined fluid collection, evaluation for inflammatory carcinoma should be completed with mammography or breast biopsy [6].…”

Breast clinic referrals: can mastalgia be managed in primary care?

“…However, this situation could be called pain, and mastalgia could be defined as a pain that continues more than five days and affects daily life [3]. During the evaluation of an abscess, ultrasound is the first-line investigation due to its painless application and because it provides regular breast evaluation during the therapy [4]. We are curious about whether mammography was used as an imaging modality during the evaluation of patients with ''mastalgia plus abscess''?…”