Breast Abscess

1st tests to order
breast ultrasound diagnostic needle aspiration drainage cytology of nipple discharge or sample from fine-needle aspiration milk, aspirate, discharge, or biopsy tissue for culture and sensitivity histopathological examination of biopsy tissue
Tests to consider

pregnancy test blood culture and sensitivity mammogram milk for leukocyte counts and bacteria quantification culture from swab/aspirate from infant's and mother's oral cavity and nasopharynx FBC tuberculin skin test (PPD)
Treatment details
Acute
lactational mastitis

symptoms not severe or not prolonged: no systemic signs and negative culture o effective milk removal and supportive care symptoms severe or prolonged or systemic signs: MRSA excluded by culture or not prevalent in area and no penicillin allergy o oral anti-staphylococcal penicillin o effective milk removal and supportive care o antifungal therapy for mother and infant o vancomycin or other antibiotic with activity against MRSA and re-assess diagnosis o effective milk removal and supportive care o antifungal therapy for mother and infant symptoms severe or prolonged or systemic signs: MRSA confirmed by culture or prevalent in area, or penicillin allergy o non-beta-lactam antibiotic o effective milk removal and supportive care o antifungal therapy for mother and infant o vancomycin (if not already used first-line) or other antibiotic with activity against MRSA and reassess diagnosis o effective milk removal and supportive care o antifungal therapy for mother and infant
non-lactational mastitis in adults and adolescents
adults: MRSA excluded by culture or not prevalent in area and no penicillin allergy o oral anti-staphylococcal penicillin or topical therapy plus supportive care
switch to appropriate therapy for underlying cause if needed vancomycin or other antibiotic with activity against MRSA and re-assess diagnosis switch to appropriate therapy for underlying cause if needed adults: MRSA confirmed by culture or prevalent in area or penicillin allergy o non-beta-lactam antibiotic plus supportive care o switch to appropriate therapy for underlying cause if needed o vancomycin (if not already used first-line) or other antibiotic with activity against MRSA and reassess diagnosis o switch to appropriate therapy for underlying cause if needed adolescents (age 12-17 years): MRSA excluded by culture or not prevalent in area and no penicillin allergy o oral anti-staphylococcal penicillin plus supportive care o re-assess diagnosis and treatment adolescents (age 12-17 years): MRSA confirmed by culture or prevalent in area or penicillin allergy o non-beta-lactam antibiotic plus supportive care o re-assess diagnosis and treatment
o o o
mastitis in neonates, infants, and children (<12 years)
MRSA excluded by culture or not prevalent in area and no penicillin allergy o intravenous anti-staphylococcal penicillin or first-generation cephalosporin plus supportive care o re-assess diagnosis and treatment MRSA confirmed by culture or prevalent in area or penicillin allergy o non-beta-lactam antibiotic plus supportive care o re-assess diagnosis and treatment
breast abscess
adult: MRSA excluded by culture or not prevalent in area and no penicillin allergy o intravenous or oral antibiotic with activity against methicillin-sensitive staphylococci plus supportive care o re-assess diagnosis and treatment o surgical intervention adult: MRSA confirmed by culture or prevalent in area or penicillin allergy o non-beta-lactam antibiotic plus supportive care o re-assess diagnosis and treatment o surgical intervention neonate, infant, or child: MRSA excluded by culture or not prevalent in area and no penicillin allergy o antibiotic with activity against methicillin-sensitive staphylococci plus supportive care o re-assess diagnosis and treatment o surgical intervention neonate, infant, or child: MRSA confirmed by culture or prevalent in area or penicillin allergy o non-beta-lactam antibiotic plus supportive care o re-assess diagnosis and treatment o surgical intervention
Ongoing
breast abscess post acute intervention
consideration of further surgical intervention
recurrence of mastitis and/or breast abscess
re-assessment and treatment
Definition
Mastitis is inflammation of the breast with or without infection. Mastitis with infection may be lactational (puerperal) or non-lactational (e.g., duct ectasia). Non-infectious mastitis includes idiopathic granulomatous inflammation and other inflammatory conditions (e.g., foreign body reaction). A breast abscess is a localised area of infection with a walled-off collection of pus. It may or may not be associated with mastitis.
Epidemiology
The global prevalence of mastitis in lactating women is approximately 1% to 10% but may be higher. [1] [2] [3] [4] [5] Duct ectasia (peri-ductal mastitis or dilated ducts associated with inflammation) occurs in 5% to 9% of non-lactating women. Breast abscess develops in 3% to 11% of women with mastitis with a reported incidence of 0.1% to 3% in breastfeeding women. [4] [6] [7] Approximately 50% of infants with neonatal mastitis will develop a breast abscess. [8] Tubercular mastitis is rare, even in TB-endemic countries, with a reported incidence between 0.1% and 3%. [9] Mammary fistula occurs in 1% to 2% of women. [6] Idiopathic granulomatous mastitis is a very rare breast condition. [10]
Aetiology
Mastitis may occur with or without infection. Infectious mastitis and breast abscess are usually caused by bacteria colonising the skin. Cases due to Staphylococcus aureus are by far the most common, followed by those due to coagulase-negative staphylococci. The majority of S aureus isolates are now resistant to methicillin. [11] [12] Breast infections may sometimes (up to 40% of abscesses) be polymicrobial, with isolation of aerobes (Staphylococcus, Streptococcus, Enterobacteriaceae, Corynebacterium, Escherichia coli, and Pseudomonas) as well as anaerobes (Peptostreptococcus, Propionibacterium, Bacteroides, Lactobacillus, Eubacterium, Clostridium, Fusobacterium, and Veillonella). [8] [11] [13] [14] [15] [16] Anaerobes are sometimes isolated in abscesses and chronic recurrent cases. A study of primary and recurrent breast abscesses showed that smokers were more likely to have anaerobes recovered (isolated in 15% of patients). [17]
More unusual pathogens may include Bartonella henselae (the agent of cat scratch disease), mycobacteria (TB and atypical mycobacteria), Actinomyces, Brucella, fungi (Candida and Cryptococcus), parasites, and maggot infestation. Unusual breast infections may be the initial presentation of HIV infection. [18] [19] Non-infectious mastitis may result from underlying duct ectasia (peri-ductal mastitis or plasma cell mastitis) and infrequently foreign material (e.g., nipple piercing, breast implant, or silicone). [20] [21] Granulomatous (lobular) mastitis is a benign disease of unknown aetiology. [10]
Pathophysiology
In lactational mastitis, milk stasis or milk overproduction, coupled with infection from bacteria entering the breast via a traumatised nipple (e.g., cracked or fissured) and/or from the infant's mouth, can lead to mastitis. [5] View image Transient breast enlargement from maternal hormones in neonates makes them vulnerable to mastitis. In duct ectasia (dilated ducts associated with inflammation), the mammary duct-associated inflammatory disease sequence involves squamous metaplasia of lactiferous ducts. This causes blockage (obstructive mastopathy) with peri-ductal inflammation and possible duct rupture. [6] View image Inflamed ducts are prone to bacterial infection. [22] [23] Left untreated, mastitis may cause tissue destruction resulting in an abscess. A lactational abscess tends to be located in the peripheral breast. Abscesses unrelated to breastfeeding are more commonly sub-areolar in location. An abscess may also occur without apparent preceding mastitis. Rupture of an abscess can lead to a draining sinus with a resulting fistula. In tubercular mastitis, mycobacterial bacilli can enter the breast from:

Direct inoculation (primary infection) via a nipple abrasion Distant portals (secondary infection), such as lymphatic spread, haematogenous (miliary) dissemination, or contiguous spread (e.g., empyema necessitans).
TB of the breast may present with a nodular, diffuse, or sclerosing reaction. The most common presentation is a painless lump with or without a sinus tract. Most cases of tuberculous mastitis are secondary, and infection occurs via contiguous spread from lymphatics (most commonly axillary, followed by cervical or mediastinal nodes) or less commonly from the pleura or chest wall or via the haematogenous route. Primary TB of the breast is rare. In some cases tubercular mastitis may be mistaken for breast carcinoma. View image Necrotising granulomas are the histopathological hallmark of TB infection. In idiopathic granulomatous mastitis, non-necrotising granulom atous inflammation is centred on lobules that clinically may result in a painless mass. View image
Classification
Types of mastitis and breast abscess

Lactational mastitis: breast inflammation with or without infection associated with breastfeeding. Non-lactational mastitis: breast inflammation associated with or without infection in the nonlactating breast. Non-infectious mastitis: breast inflammation due to a non-infectious and/or idiopathic aetiology. Subclinical mastitis: refers to the finding of a raised sodium/potassium ratio and interleukin in milk without clinical mastitis. [1] Breast abscess: localised breast infection with a walled-off collection of pus.
Primary prevention
Good breastfeeding habits (e.g., emptying breasts fully and proper latching) and proper nipple hygiene may help to minimise the risk of developing lactational mastitis. Sterile equipment and techniques should be used for nipple piercing.
Secondary prevention
Prompt treatment of mastitis will prevent complications such as a breast abscess. Breastfeeding should be encouraged if feasible during lactation. Smoking cessation should also be encouraged to minimise the risk of recurrence. Mastitis may increase the risk of transmission of HIV through breastfeeding. [1] Therefore, if an HIV-positive woman develops mastitis or an abscess, she should avoid breastfeeding from the affected side while the condition persists. [1]
History & examination

Key diagnostic factorshide all
flu-like symptoms, malaise, and myalgia (common)
Patients with mastitis and/or breast abscess may complain of systemic symptoms.
fever (common)
Mastitis may occur with or without a pyrexia >38C (>100.4F). Breast abscess may or may not be accompanied by fever.
breast pain (common)
Usually sharp, shooting breast pain, especially with breastfeeding, may indicate mastitis.
decreased milk outflow (common)
Milk stasis may be associated with the development of mastitis.
breast warmth (common)

Inflammatory symptom suggestive of mastitis and a possible underlying abscess. Lactational mastitis tends to involve more peripheral wedge-shaped areas.
breast tenderness (common)

Inflammatory sign suggestive of mastitis and/or abscess. Lactational mastitis tends to involve more peripheral wedge-shaped areas.
breast firmness (common)

Inflammatory symptom suggestive of mastitis and a possible underlying abscess. Lactational mastitis tends to involve more peripheral wedge-shaped areas.
breast swelling (common)

Inflammatory symptom suggestive of mastitis and/or abscess. Lactational mastitis tends to involve more peripheral wedge-shaped areas. Swelling may indicate skin oedema and/or underlying abscess formation. [8]
breast erythema (common)

Inflammatory sign suggestive of mastitis and a possible underlying abscess. View imageView image Lactational mastitis tends to involve more peripheral wedge-shaped areas.
breast mass (uncommon)

May occur with a tender area of localised mastitis or breast abscess. A late abscess may result in a fluctuant palpable mass.
fistula (uncommon)
A fistula is usually associated with a draining sinus from an underlying abscess.
Other diagnostic factorshide all
nipple discharge (uncommon)

May occur with or without mastitis. Often associated with duct ectasia (dilated breast duct associated with inflammation). Purulent discharge is usually indicative of infection.
nipple inversion/retraction (uncommon)
Infrequently seen with mastitis.
lymphadenopathy (uncommon)
Tender axillary lymph nodes may occur with ipsilateral breast infection.
extra-mammary skin lesions (uncommon)
Patients with mastitis and/or breast abscess may present with systemic signs including extramammary skin lesions.
Risk factorshide all

Strong female gender

Breast infection more frequently involves the female breast. Inflammation of the male breast may occur but is unusual.
women 15 to 45 years of age

Breast infection typically affects women 15 to 45 years of age, infants <2 months of age, and adolescent girls. [2] [24] [25] Women aged >30 years have a higher risk of mastitis, possibly related to milk stasis. [26]
adolescent girls
Breast infection typically affects women 15 to 45 years of age, infants <2 months of age, and adolescent girls. [2] [24] [25]
infants <2 months of age

Breast infection typically affects women 15 to 45 years of age, infants <2 months of age, and adolescent girls. [2] [24] [25] Transient breast enlargement from maternal hormones in neonates makes them vulnerable to mastitis.
poor breastfeeding technique
Poor breastfeeding positioning, or oral infection, tongue-tie, a skin infection, and nappy rash in the infant may be associated with the development of lactational mastitis.
lactation
Lactational mastitis is more common at 6 to 8 weeks of breastfeeding or at weaning. Mastitis is uncommon during pregnancy itself.
milk stasis

Associated with infectious (lactational) and non-infectious mastitis. May result from inadequate drainage, blocked ducts, milk oversupply, external pressure on the breast (e.g., tight-fitting bra), infrequent feeding, or rapid weaning. [1]
nipple injury

Nipple cracks and fissures permit bacteria to gain entry into the breast. Injury may occur when an older teething baby bites a nipple or from use of a breast pump that generates excessive vacuum.
previous mastitis
Women who have had mastitis have an increased rate of recurrence with subsequent births (approximately 12%).
prolonged mastitis (breast abscess)
Prolonged mastitis may be associated with breast abscess formation.
prior breast abscess (breast abscess)
There is a high rate of recurrence with a remote history of prior breast abscesses.
shaving or plucking areola hair
Pulling hair from the areola may cause a Montgomery follicle abscess with potential for more widespread infection.
anatomical breast defect, mammoplasty, or scar
Altered duct structure may interfere with milk flow and predispose to mastitis.
other underlying breast condition
Particularly breast cancer.
nipple piercing
Breast infection may develop up to 52 weeks after piercing in 10% to 20% of cases. [21]
foreign body

Silicone and breast implants may cause mastitis with or without infection. Silicone mastitis may cause a hard, tender, erythematous breast mass.
skin infection

Dermatoses, such as psoriasis or eczema, may cause nipple fissures that result in recurrent mastitis. Afflicted women are also more likely to harbour Staphylococcus aureus. Maternal skin infections may be linked to neonatal mastitis. In neonates, extra-mammary skin infections may be associated with mastitis. [27]
Staphylococcus aureus carrier
The vast majority of cases of infectious mastitis and breast abscess are caused by S aureus.
immunosuppression

Patients with diabetes or HIV infection, and those on immunosuppression therapy are at risk for developing breast infections. [18] Diabetes mellitus is strongly associated with breast abscess in non-lactating women. [28]
Weak hospital admission
Epidemic (hospital-acquired) puerperal mastitis should be considered in any patient with signs of breast infection during or after a hospital admission.
breast trauma

Trauma to the breast may infrequently result in inflammation. Domestic violence in such cases should always be considered. A traumatised neonatal breast bud, even from minor manipulation, is highly prone to developing mastitis.
primiparity
Found to be a risk factor for both mastitis and breast abscess in some studies but not in others. [1]
overabundant milk supply

For example, as may occur with lactation for twins or higher multiples. May predispose to milk stasis. [1]
post-maturity (breast abscess)
Gestational age of 41 weeks or more is associated with an increased risk of breast abscess. [26]
complications of delivery
May increase the risk of lactational mastitis. [1]
maternal fatigue
Stress, sleep deprivation, exhaustion, and returning to work have all been associated with lactational mastitis.
tight clothing
Believed to promote milk stasis. [1]
antifungal nipple cream
Repeat application of antifungal cream for nipple thrush may cause nipple injury and possibly a change in normal flora. [3]
fibrocystic breast disease
May interfere with milk flow.
cigarette smoking

Smoking hinders the breast milk ejection reflex and raises the risk of engorgement and subsequent lactational mastitis. Smoking is also associated with non-lactational mastitis in young women, as well as primary and recurrent breast abscess. [29] [30]
vaginal manipulation (breast abscess)
Resulting transient bacteraemia is believed to be associated with anaerobic breast abscess formation. [31]
poor nutrition

Thought to predispose to mastitis. Vitamin A deficiency promotes squamous metaplasia, which is thought to cause obstructive mastopathy. [1]
Diagnostic tests
1st tests to orderhide all
Test Result
breast ultrasound
For an erythematous area, ultrasonography helps to identify an underlying abscess. [32] [33] [34] Abscesses usually form a hypoechoic lesion. View image This is the preferred imaging modality in adolescents, and is applicable in neonates with suspected breast infection. [35]
diagnostic needle aspiration drainage
hypoechoic lesion (abscess); may be well circumscribed, macrolobulated, irregular, or ill defined with possible septae
A breast abscess can be drained by needle aspiration for therapeutic and diagnostic purposes. View image Can be directed by ultrasound guidance.
cytology of nipple discharge or sample from fine-needle aspiration
purulent fluid indicates a breast abscess
Nipple discharge and fine-needle aspirate should be sent for cytological evaluation, looking for underlying malignancy in addition to infection.
milk, aspirate, discharge, or biopsy tissue for culture and sensitivity
if present: infection and/or malignancy demonstrated
Milk, aspirates, nipple, or sinus discharge, and biopsy tissue should be sent for bacterial (aerobic and anaerobic) culture and sensitivity. positive culture indicates infection Fungal and mycobacterial studies may be performed, but usually only if the condition is refractory to antibiotics. Mycobacteria are usually demonstrable in only 12% to 33% of mammary TB. [9] [42]
histopathological examination of biopsy tissue
Excised tissue should be sent for histopathological evaluation, especially in refractory and recurrent cases. Skin-punch biopsy can be undertaken to diagnose inflammatory breast carcinoma.
if present: infection, granulomatous inflammation, or malignancy demonstrated.
Tests to considerhide all
Test pregnancy test may be positive
Result
If mastitis develops unexpectedly, such as in an adolescent, a pregnancy test should be considered.

blood culture and sensitivity
If systemic infection suspected, should be sent for bacterial (aerobic and anaerobic) culture and sensitivity. Fungal and mycobacterial studies may be performed, but usually only if the condition is refractory to antibiotics. Results guide appropriate therapy.
mammogram
positive culture indicates systemic infection
Useful to help identify underlying breast lesions. Mammographic findings of breast infection and abscess are often non-specific and may mimic cancer. [33] [34] [38] [39] View image It is usually too painful to perform a mammogram if an abscess is present. Should be ordered (following resolution of the acute phase) in women >40 years of age and whenever the presentation is complicated or atypical, or malignancy is suspected. [40]
milk for leukocyte counts and bacteria quantification leukocytes >10^6/mL milk and bacteria Expressed milk or a midstream sample can be sent for leukocyte counts and bacteria quantification. [37] <10^3/mL milk indicates non-infectious
non-specific findings in acute phase; may demonstrate underlying lesion if performed after the acute phase
Although the presence of pathogenic bacteria and/or high bacterial counts (>10^3/mL of milk) indicates mastitis, the predictive value is low. Therefore, the presence of bacteria in milk does not necessarily indicate infection. [1]
mastitis; leukocytes >10^6/mL milk and bacteria >10^3/mL milk indicates infectious mastitis
culture from swab/aspirate from infant's and mother's oral cavity may be positive for Staphylococcus aureus if a and nasopharynx carrier
For recurrent cases of lactational mastitis, cultures
from the infant's and mother's oral cavity and nasopharynx are submitted to determine their staphylococcal carrier status.
FBC
Indicated for patients who appear toxic or have an abscess, recurrent infection, or treatment failure. Also indicated in neonates.
tuberculin skin test (PPD)
normal; leukocytosis with infection; neutropenia with immunosuppression
If active TB is suspected or needs to be ruled out. Microbiological studies and/or biopsy should also be performed.
often positive with active TB
Differential diagnosis
Condition

Differentiating signs/symptoms
Differentiating tests
Breast engorgement
Engorgement usually occurs on the third to fifth post-partum day. There may be bilateral generalised breast pain, firmness, erythema, warmth, and a mild fever (milk fever), but there is usually no oedema. Relieved by frequent emptying of the breasts (e.g., breastfeeding). There is usually no evidence of nipple trauma, features of breast inflammation, or fever. Nipple vasospasm (Raynaud's phenomenon) may manifest with nipple pain. Nipple sensitivity with breastfeeding usually subsides once suckling begins, whereas pain from trauma or infection persists or increases.
Usually becomes clinically apparent as breastfeeding continues.
Nipple sensitivity
Usually becomes clinically apparent as breastfeeding continues.
Galactocoele
A milk retention cyst may cause a tender palpable breast lump, but there are usually no sharp shooting pains and no signs of breast inflammation or systemic illness.
A galactocoele appears on ultrasound as a well-defined lesion with a thin echogenic wall, which may contain coarse calcification. A breast abscess may also be well circumscribed, macrolobulated, irregular, or ill defined with possible septae. Galactocele aspiration yields nonpurulent milk. Ultrasound may help to diagnose benign cystic breast tissue. Mammography is only indicated to help with diagnosis of fibrocystic disease in older women, not adolescents, because the density of breast tissue in adolescents makes interpretation difficult.
Fibrocystic breasts
Painful breast tissue before menses improves during menstruation. Lumps are palpated mainly in the upper outer quadrant. A non-bloody nipple discharge may be reported.
Mastodynia
Mastalgia may be cyclic or noncyclic with menstruation. There should be no symptoms or signs of breast inflammation. Trauma may cause fat necrosis, which could manifest as a breast mass. Signs of inflammation are uncommon. The signs and symptoms of breast cancer may be similar to those of breast infection. It may present as a hard, irregular, painless mass that may or may not be fixed to the underlying tissue. There may be a nipple discharge, nipple or skin retraction, skin oedema (peau d'orange), and regional lymphadenopathy. Paget's disease will involve the nipple. Inflammatory breast cancer may resemble mastitis with breast enlargement, warmth, tenderness, oedema, erythema, and possible skin discoloration.
Specific tests are not indicated. Diagnosis is based on history and examination.
Breast trauma
Imaging studies may mimic carcinoma (as also occurs on occasion with breast infection). A biopsy may be indicated for a definitive diagnosis.
Primary invasive breast cancer
Imaging studies, such as mammography, may reveal a mass, increased density, and microcalcification. Percutaneous biopsy (recommended method), or surgical excision (excisional biopsy) if indicated, is necessary to establish the diagnosis. A skin-punch biopsy for inflammatory breast carcinoma will show tumour infiltration of dermal lymphatics.
Fibroadenoma
Presents typically as a non-tender, rubbery, well-circumscribed, and mobile mass.
Imaging studies, such as breast ultrasound and mammography, generally reveal a solid, homogeneous, well-circumscribed, avascular mass with occasional coarse calcification. Pathological examination will demonstrate a fibroepithelial lesion.
Fat necrosis
Typically results in a tender, round, firm breast mass. The skin may be dimpled over such a lump. Inflammation is usually not a common feature unless there is an associated infection. May manifest with one or more hard, irregular, mobile, discrete, painless, palpable masses. Complications arising from diabetes such as retinopathy, neuropathy, and nephropathy may be present. Breast lesions tend to be recurrent and bilateral. Patients may have other autoimmune diseases. Thrombophlebitis of a superficial vein may cause breast pain and a cord-like mass with possible skin dimpling, usually in the lower quadrants. The cord is accentuated by traction, elevation of the breast, or abduction of the ipsilateral arm.
Breast imaging findings may not be specific. A breast biopsy is the most accurate means of providing a definitive diagnosis.
Diabetes

Breast imaging studies may be nonspecific and can mimic cancer. Biopsy shows sclerosing lobular lymphocytic mastitis.
Mondor's disease
Mammography and a microbiology work-up are usually negative.
Systemic lupus erythematosus
A history of SLE is highly suggestive. There may be a tender mass lesion with possible skin changes. Chronic mastitis with flares may be reported.
Serological evidence of lupus is usually present. Mammography may show architectural distortion, fat necrosis, or calcifications. [43] A biopsy may help, showing lupus panniculitis. Laboratory tests may show
Necrotising
Patients may have fever, chills,
fasciitis
and extreme pain associated with rapidly advancing skin erythema, and possible cyanosis, vesicles, bullae, ulcers, crepitation, and a black necrotic eschar. Examination by an experienced surgeon is critical. A history of prior trauma, skin biopsy, or a surgical wound in the mammary region may be reported. Presents mainly around hair follicles in the axilla and intertriginous regions under the breasts. Lesions range from comedones to painful lumps, abscesses, and skin scarring, and these may be associated with a purulent discharge. There is localised sternal pain, often exacerbated with respiration or activity. Pain may radiate. A palpable swelling with redness is often located about 4 cm from the sternal edge. A breast examination is usually unremarkable. Benign breast enlargement may be transient. The breast bud in such cases is not red or tender. If present, a nipple discharge is milky and not purulent.
leukocytosis, elevated urea, and reduced serum sodium level. Infection can be diagnosed with rapid streptococcal diagnostic kits, if available. Microbiology studies and excisional deep skin biopsy may be helpful in diagnosing and identifying the causative organisms and confirming the diagnosis.
Hidradenitis suppurativa
A biopsy will show acute and chronic folliculitis with a possible foreign body giant cell inflammation.
Costochondritis
Tests are not necessary.
Neonatal breast hypertrophy
Tests are not necessary.
Gigantomastia
Massive hypertrophy of the breasts may occur early in pregnancy. There may be associated skin necrosis.
Microbiology studies may be required to exclude underlying infection.
Step-by-step diagnostic approach

The diagnosis of mastitis and/or breast infection warrants a detailed history to include potential risk factors, along with a thorough physical examination. While the diagnosis of breast infection is usually made on clinical grounds, investigations may be necessary in certain cases.
Presence of risk factors

Risk factors strongly associated with mastitis include:

Female gender Age 15 to 45 years or adolescence Infants <2 months of age Lactation, particularly after 6 to 8 weeks of breastfeeding or at weaning Poor breastfeeding technique (may also be due to infant factors such as tongue-tie) Milk stasis (may be secondary to poor breastfeeding technique or tight-fitting bra) Nipple injury Previous mastitis Shaving or plucking areolar hair Anatomical breast defect, mammoplasty, or scar Other underlying breast condition particularly breast cancer Nipple piercing Foreign body (e.g., silicone implant) Skin infection Positive carrier status for Staphylococcus aureus Presence of a hospital-acquired infection Immunosuppression (including diabetes mellitus).
Breast abscess is strongly associated with prolonged mastitis and prior breast abscess. These factors need to be specifically considered when a patient history is taken.
Focused history
A focused history needs to evaluate for:
Symptoms related to possible breast inflammation (e.g., warmth, pain, swelling, firmness, erythema) Possible abscess (tender lump) Milk stasis (decreased milk output) Systemic infection (fever, malaise, myalgia) Nipple discharge, which may be present with mastitis and occurs more often with duct ectasia (dilated ducts with inflammation); however, purulent discharge is usually indicative of breast infection.
Physical examination
The diagnosis of breast infection is usually made on clinical grounds. General physical examination includes:

Recording the patient's temperature: mastitis may occur with or without a pyrexia of >38C (100.4F); breast abscess may or may not be accompanied by fever. Checking for other signs of systemic infection (e.g., flu-like illness, possible extra-mammary skin lesions) Examining for distant skin infections Checking for possible extra-mammary TB infection, including signs of pleural-pulmonary disease, lymphadenitis, and erythema nodosum.
Breast examination consists of a thorough examination of both breasts and axillary lymph nodes:

Tender axillary lymph nodes may occur with ipsilateral breast infection. Signs of breast inflammation include breast tenderness, warmth, firmness, swelling, and erythema. Lactational mastitis tends to involve more peripheral wedge-shaped areas of the breast. A tender palpable breast mass may indicate localised mastitis or breast abscess. A fluctuant mass may be palpated in the case of a late breast abscess. Rarely, nipple retraction or inversion may occur with mastitis.
If a fistula is present, it is usually associated with a draining sinus from an underlying abscess.
Initial investigations
If mastitis develops unexpectedly, such as in an adolescent, a pregnancy test should be considered. Ultrasonography, if available, of an erythematous breast area may help in the initial work-up to diagnose an underlying abscess and can direct needle aspiration drainage. [32] View imageView image An abscess may appear as a well-circumscribed, macrolobulated, irregular, or ill-defined echo-poor compound cystic lesion with possible septae. [33] [34] A hypoechoic rim may indicate a thick wall of a chronic abscess. Ultrasound is the preferred imaging modality in adolescents, and is applicable in neonates with suspected breast infection. [35] Increased breast density results in the reduced efficacy of mammography in young women. A breast abscess can be drained by needle aspiration for therapeutic and diagnostic purposes. Aspirated material (fluid, pus, blood) from needle drainage of an abscess should be sent for microbiology studies and cytology to look for underlying malignancy in addition to infection.
Microbiology and pathology investigations

For routine cases of mastitis, a biopsy is not necessarily indicated. For all other cases, such as a suspected abscess, atypical presentation, uncertain diagnosis, or a potential complication (e.g., recurrent infection or treatment failure), a biopsy may be warranted. A biopsy includes fine-needle aspiration biopsy (which can be performed with/without ultrasound guidance) and tissue biopsy (which may be an excisional or incisional biopsy involving a core-needle biopsy, other vacuum-assisted device, or a formal surgical procedure). Fine-needle aspiration biopsy and/or nipple discharge should be sent for evaluation of a possible malignancy as well as infection. [36] View image Tissue biopsy permits examination of involved tissue for infection, granulomatous inflammation, and malignancy. Excised tissue should be sent for histopathological evaluation (cytology) for a possible malignancy and infection (e.g., fungal stains and acid-fast bacilli for TB), especially in refractory and recurrent cases. Skin-punch biopsy can be undertaken to diagnose inflammatory breast carcinoma. Milk, nipple discharge, aspirated material, or excised tissue can be sent for Gram stain, culture (aerobic and anaerobic) with sensitivity, and fungal and mycobacterial studies. Culture may be performed in all patients or only in selective cases such as:

Hospital-acquired infection Severe or unusual cases Failure to respond to antibiotics within 2 days Recurrent mastitis. [1]
Expressed milk or a midstream milk sample can be sent for leukocyte counts and microbiology studies, including bacteria quantification. [37] Endogenous breast flora is similar to that present on the skin. Although the presence of pathogenic bacteria and/or high bacterial counts (>10^3/mL of milk) indicates mastitis, the predictive value is low. Therefore, the presence of bacteria in milk does not necessarily indicate infection. [1] Moreover, many lactating women who have potentially pathogenic bacteria on their skin or in their milk will not develop mastitis. [1] Alternatively, many women who do develop mastitis may not have pathogenic organisms in their milk. [1] Blood cultures should be obtained in patients who appear toxic and in neonates before initiation of antibiotic therapy. In neonates, additional samples (e.g., cerebrospinal fluid, urine) should be submitted for microscopy and culture.
Mammography
Mammography may be too painful to perform on a breast with an abscess. Also, mammographic findings of breast infection and abscess are non-specific. [33] [34] [38] [39] Breast infection, including TB, can cause the following mammographic findings:

No abnormality Focal/diffusely increased density Architectural distortion A spiculated mass Skin thickening or retraction Micro-calcification.
The findings may mimic cancer. Therefore, mammography is most useful after the acute phase has resolved. At this stage it can help to identify underlying breast lesions. It should be ordered in women >40 years of age, and whenever the presentation is complicated or atypical, or malignancy is suspected. [40]
Additional investigations
A FBC with a differential and blood cultures are indicated in patients with suspected systemic infection, abscess, recurrent infection, or treatment failure. Previously, investigations recommended in this setting included a serum prolactin level, although evidence now suggests it is not of value. [41] Tests to diagnose possible TB include a tuberculin skin test (PPD, often positive in patients with active disease), microbiology studies, and/or biopsy. When lactational mastitis is suspected, examination of the neonate should be considered, specifically with regard to the oral cavity, skin, and nappy area. For recurrent cases of lactational mastitis, cultures from the infant's and mother's oral cavity and nasopharynx are submitted to determine their staphylococcal carrier status.
Diagnostic criteria
Milk counts [37]
Lactational mastitis can be classified according to milk leukocyte counts and quantification for bacteria.
Leukocyte counts and bacteria quantification in breast milkChart produced by author using data from Thomsen AC, Espersen T, Maigaard S. Am J Obstet Gynecol. 1984;149:492-495 Endogenous breast flora is similar to that present on the skin. Although the presence of pathogenic bacteria and/or high bacterial counts (>10^3/mL of milk) indicates mastitis, the predictive value is low. Therefore, the presence of bacteria in milk does not necessarily indicate infection. [1] Moreover, many lactating women who have potentially pathogenic bacteria on their skin or in their milk will not develop mastitis. [1] Alternatively, many women who do develop mastitis may not have pathogenic organisms in their milk. [1]
Treatment Options
Acute
Patient group
Treatment line
Treatmenthide all
lactational mastitis
effective milk removal and supportive care
symptoms not severe or not prolonged: no 1st systemic signs and negative culture
In an early stage, when signs and symptoms of mastitis have not been present for more than 12 to 24 hours, it may be possible to manage the condition without antibiotics. [46] [47] [48] However, antibiotics are required if the pain becomes severe, if milk or blood culture is positive, or if there are any signs of systemic infection. Breastfeeding should continue frequently (e.g., breastfeeding 8 to 12 times per day) to promote effective milk removal. Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used. The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). The patient should be advised to increase her fluid intake, try warm and/or cold compresses, and have bed rest.
oral anti-staphylococcal penicillin
symptoms severe or prolonged or systemic signs: 1st MRSA excluded by culture or not prevalent in area and no penicillin allergy
Antibiotics are indicated for patients with acute pain, severe symptoms, or symptoms lasting more than 12 to 24 hours; fever or any other signs of systemic infection; or positive microbiology studies. An oral penicillin with activity against methicillinsensitive staphylococci could be used first if MRSA has been excluded by culture or if MRSA is not known to be prevalent in the area, and the patient is not allergic to penicillin. Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. Treatment course: 10 to 14 days.
Primary Options
flucloxacillin : 250-500 mg orally four times daily

OR
Acute Patient group
Treatment line
Treatmenthide all
dicloxacillin : 250-500 mg orally four times daily

OR
cloxacillin : 250-500 mg orally four times daily

plus
[?]
Breastfeeding should continue frequently (e.g., breastfeeding 8 to 12 times per day) to promote effective milk removal. Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used. The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). The patient should be advised to increase her fluid intake, try warm and/or cold compresses, and have bed rest.
antifungal therapy for mother and infant

adjunct
[?]
If nipple candidiasis is diagnosed, both mother and infant must be treated simultaneously. Items that have been in contact with maternal nipples should be boiled for 20 minutes. Clothing that is in contact with the breast should be cleaned with a dilute bleach solution. [60] Topical cream should be used in the mother, combined with topical suspension for use in the infant. Treatment course: continue for 2 days after resolution of infection.
Primary Options
nystatin topical : mother: (100,000 units/g) apply to the affected area(s) twice daily
and
nystatin : infant: (100,000 units/mL) 2 mL orally four times daily
Acute Patient group
Treatment line
OR
Treatmenthide all
miconazole topical : mother: (2%) apply to the affected area(s) twice daily
and

OR
ketoconazole topical : mother: (2%) apply to the affected area(s) twice daily
and

vancomycin or other antibiotic with activity against MRSA and reassess diagnosis
2nd
Infections should begin to respond within 48 hours. If the infection is worsening despite oral therapy, intravenous vancomycin should be considered instead. Alternatively, other antibiotics with activity against MRSA may be used (but experience with these other agents in treating mastitis is limited). Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. In refractory cases an ultrasound scan should be performed looking for possible underlying abscess, a biopsy should be considered, and cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-resistant pathogen. If a fistula is detected, it needs to be excised (fistulectomy) along with its feeding duct. [50] Antibiotic treatment course: 10 to 14 days.
Primary Options
vancomycin HCl : 15 mg/kg intravenously every 12 hours,
Acute Patient group
Treatment line
Treatmenthide all
maximum 4 g/day
Secondary Options
linezolid : 600 mg intravenously/orally every 12 hours

OR
tigecycline : 100 mg intravenously as a single dose, followed by 50 mg every 12 hours

OR
daptomycin : 6 mg/kg intravenously once daily

plus
[?]
Breastfeeding should continue frequently (e.g., breastfeeding 8 to 12 times per day) to promote effective milk removal. Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used. The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). The patient should be advised to increase her fluid intake, try warm and/or cold compresses, and have bed rest.

adjunct
[?]
Primary Options
Acute Patient group
Treatment line
Treatmenthide all
and

OR
and

OR
and

non-beta-lactam antibiotic
symptoms severe or prolonged or systemic signs: 1st MRSA confirmed by culture or prevalent in area, or penicillin allergy
Antibiotics are indicated for patients with acute pain, severe symptoms, or symptoms lasting more than 12 to 24 hours; fever or any other signs of systemic infection; or positive microbiology studies. If MRSA has been confirmed by culture, or if MRSA is known to be prevalent in the area, then a broad-spectrum antibiotic with communityacquired MRSA (CA-MRSA) coverage is given. This would normally be an oral antibiotic. Generally most of these patients are outpatients, so the MRSA infection is community-acquired. This type of antibiotic would also be appropriate if the patient is allergic to penicillin. The mother should not continue to breastfeed in
Acute Patient group
Treatment line
Treatmenthide all
the first 2 months if trimethoprim/sulfamethoxazole is used. Doxycycline can be used for CA-MRSA infections, during which time the mother should not breastfeed. Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. Vancomycin may be indicated first-line in hospitalised patients with severe infection. This covers hospital-acquired MRSA. Treatment course: 10 to 14 days.
Primary Options
clindamycin : 300-450 mg orally four times daily

OR
trimethoprim/sulfamethoxazole : 160/800 mg orally twice daily

OR
vancomycin HCl : 15 mg/kg intravenously every 12 hours, maximum 4 g/day

Secondary Options
doxycycline : 100 mg orally twice daily

plus
[?]

Generally, breastfeeding should continue frequently (e.g., breastfeeding 8 to 12 times per day) to promote effective milk removal. However, if the mother is treated with doxycycline she should not breastfeed. Also, she should not breastfeed if the infant is younger than 2 months old and she is being treated with trimethoprim/sulfamethoxazole. Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used. The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol,
Acute Patient group
Treatment line
Treatmenthide all
ibuprofen). The patient should be advised to increase her fluid intake, try warm and/or cold compresses, and have bed rest.

Primary Options
adjunct and
[?] nystatin : infant: (100,000 units/mL) 2 mL orally four times daily

OR
and

OR
Acute Patient group
Treatment line
and
Treatmenthide all

vancomycin (if not already used first-line) or other antibiotic with activity against MRSA and re-assess diagnosis
2nd
Infections should begin to respond within 48 hours. If the infection is worsening despite oral therapy, intravenous vancomycin should be considered instead. Alternatively, other antibiotics with activity against MRSA may be used (but experience with these other agents in treating mastitis is limited). Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. In refractory cases an ultrasound scan should be performed looking for possible underlying abscess, a biopsy should be considered, and cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-resistant pathogen. If a fistula is detected it needs to be excised (fistulectomy) along with its feeding duct. [50] Antibiotic treatment course: 10 to 14 days.
Primary Options

Secondary Options

OR

OR

plus effective milk removal and supportive care
Acute Patient group
Treatment line [?]
Treatmenthide all
Generally, breastfeeding should continue frequently (e.g., breastfeeding 8 to 12 times per day) to promote effective milk removal. However, if the mother is treated with doxycycline she should not breastfeed. Also, she should not breastfeed if the infant is younger than 2 months old and she is being treated with trimethoprim/sulfamethoxazole. Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used. The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). The patient should be advised to increase her fluid intake, try warm and/or cold compresses, and have bed rest.

adjunct
[?]
Primary Options
and

OR
miconazole topical : mother: (2%) apply to the affected
Acute Patient group
Treatment line
Treatmenthide all
area(s) twice daily

and

OR
and
nystatin : infant: (100,000 units/mL) 2 mL orally four times daily non-lactational mastitis in adults and adolescents
oral anti-staphylococcal penicillin or topical therapy plus supportive care
adults: MRSA excluded by culture 1st or not prevalent in area and no penicillin allergy
In early stages it can be difficult to differentiate between non-infectious and infectious nonlactational mastitis, so antibiotics are generally commenced in all cases. An oral penicillin with activity against methicillinsensitive staphylococci could be used first if MRSA has been excluded by culture or if MRSA is not known to be prevalent in the area, and the patient is not allergic to penicillin. Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. If infection is isolated to the nipple, then topical therapy (e.g., topical mupirocin or a polymyxincontaining preparation) may be sufficient. Supportive care includes analgesia if required. Antibiotic treatment course: 10 to 14 days.
Primary Options
Acute Patient group
Treatment line
OR
Treatmenthide all
dicloxacillin : 250-500 mg orally four times daily

OR
cloxacillin : 250-500 mg orally four times daily

OR
mupirocin topical : (2%) apply to the affected area(s) two to three times daily
OR
bacitracin/neomycin/polymyxin B topical : apply to the affected area(s) two to three times daily
switch to appropriate therapy for underlying cause if needed

plus
[?]
Antifungal therapy (e.g., fluconazole) is indicated for deep fungal infections. TB of the breast requires 6 months of anti-TB therapy including 2 months with a 4-drug combination (e.g., ethambutol, rifampin, isoniazid, and pyrazinamide) followed by 4 months with a 2drug combination (isoniazid and rifampin). [49] A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention. For post-operative wound infections, a surgeon should be consulted. Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body. For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice, and surgery is not necessary.
2nd
vancomycin or other antibiotic with activity against MRSA and reassess diagnosis
Infections should begin to respond within 48 hours. If the infection is worsening despite oral
Acute Patient group
Treatment line
Treatmenthide all
therapy, intravenous vancomycin should be considered instead. Alternatively, other antibiotics with activity against MRSA may be used (but experience with these other agents in treating mastitis is limited). Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. In refractory cases an ultrasound should be performed looking for possible underlying abscess, a biopsy should be considered, and cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-resistant pathogen. If a fistula is detected it needs to be excised (fistulectomy) along with its feeding duct. [50] Antibiotic treatment course: 10 to 14 days.
Primary Options

Secondary Options

OR

OR

plus
[?]
Antifungal therapy (e.g., fluconazole) is indicated for deep fungal infections. TB of the breast requires 6 months of anti-TB therapy including 2 months with a 4-drug combination (e.g., ethambutol, rifampin, isoniazid, and pyrazinamide) followed by 4 months with a 2drug combination (isoniazid and rifampin). [49] A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses
Acute Patient group
Treatment line

Treatmenthide all
may require surgical intervention. For post-operative wound infections, a surgeon should be consulted. Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body. For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice, and surgery is not necessary.
non-beta-lactam antibiotic plus supportive care
adults: MRSA confirmed by culture 1st or prevalent in area or penicillin allergy
In early stages it can be difficult to differentiate between non-infectious and infectious nonlactational mastitis, so antibiotics are generally commenced in all cases. If MRSA has been confirmed by culture or if it is known to be prevalent in the area, then a broadspectrum antibiotic with community-acquired MRSA (CA-MRSA) coverage is given. This is normally an oral antibiotic. Generally most of these patients are outpatients, so the MRSA infection is community-acquired. This type of antibiotic would also be appropriate if the patient is allergic to penicillin. Vancomycin may be indicated first-line in hospitalised patients with severe infection. This covers hospital-acquired MRSA. Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. Supportive care includes analgesia if required. Antibiotic treatment course: 10 to 14 days.
Primary Options

OR
Acute Patient group
Treatment line
OR
Treatmenthide all

Secondary Options


plus
[?]
Antifungal therapy (e.g., fluconazole) is indicated for deep fungal infections. TB of the breast requires 6 months of anti-TB therapy including 2 months with a 4-drug combination (e.g., ethambutol, rifampin, isoniazid, and pyrazinamide) followed by 4 months with a 2drug combination (isoniazid and rifampin). [49] A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention. For post-operative wound infections, a surgeon should be consulted. Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body. For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice, and surgery is not necessary.
vancomycin (if not already used first-line) or other antibiotic with activity against MRSA and re-assess diagnosis
2nd
Infections should begin to respond within 48 hours. If the infection is worsening despite oral therapy, intravenous vancomycin should be considered instead. Alternatively, other antibiotics with activity against MRSA may be used (but experience with these other agents in treating mastitis is limited). Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. In refractory cases an ultrasound scan should be performed looking for possible underlying abscess,
Acute Patient group
Treatment line
Treatmenthide all
a biopsy should be considered, and cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-resistant pathogen. If a fistula is detected it needs to be excised (fistulectomy) along with its feeding duct. [50] Antibiotic treatment course: 10 to 14 days.
Primary Options

Secondary Options

OR

OR


plus
[?]

Antifungal therapy (e.g., fluconazole) is indicated for deep fungal infections. TB of the breast requires 6 months of anti-TB therapy including 2 months with a 4-drug combination (e.g., ethambutol, rifampin, isoniazid, and pyrazinamide) followed by 4 months with a 2drug combination (isoniazid and rifampin). [49] A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention. For post-operative wound infections, a surgeon should be consulted. Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body. For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice, and surgery is not
Acute Patient group
Treatment line
Treatmenthide all
necessary.
oral anti-staphylococcal penicillin plus supportive care
adolescents (age 1217 years): MRSA excluded by culture 1st or not prevalent in area and no penicillin allergy
In adolescents, initial antibiotic treatment can usually be oral. Initial antibiotics for adolescents, if MRSA can be excluded, may include an oral penicillin with activity against methicillin-sensitive staphylococci (e.g., dicloxacillin, cloxacillin, or flucloxacillin, depending on availability). Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. Supportive measures include analgesia for pain relief if necessary and warm/cold compresses if tolerated. Antibiotic treatment course: 7 to 10 days.
Primary Options

OR
dicloxacillin : children <40 kg: 12.5 to 25 mg/kg/day orally given in 4 divided doses; children >40 kg: 125-250 mg four times daily
OR
cloxacillin : children <20 kg: 50-100 mg orally four times daily; children >20 kg: 250-500 mg orally four times daily
re-assess diagnosis and treatment
2nd
Infections should begin to respond within 48 hours. If there is no response after 48 hours, the patient should be re-assessed. The regimen should be broadened to include activity against MRSA. Adolescents with a systemic infection should be treated parenterally (generally with vancomycin). Alternatives include linezolid, tigecycline, or daptomycin. Supportive measures include analgesia for pain relief if necessary and warm/cold compresses if
Acute Patient group
Treatment line
Treatmenthide all
tolerated. Antibiotic treatment course: 10 to 14 days.
Primary Options

Secondary Options

OR

OR


adolescents (age 1217 years): MRSA 1st confirmed by culture or prevalent in area or penicillin allergy
In adolescents, initial antibiotic treatment can usually be oral. In areas where MRSA is prevalent or suspected, and in cases of penicillin allergy, initial treatment should include clindamycin, trimethoprim/sulfamethoxazole, or doxycycline (the latter only in children >8 years of age). Generally most of these patients are outpatients, so the MRSA infection is community-acquired. Adolescents with a systemic infection should be treated parenterally (generally with vancomycin). Also, adolescents with severe infection who are hospitalised should be treated with vancomycin to cover hospital-acquired MRSA. Supportive measures include analgesia for pain relief if necessary and warm/cold compresses if tolerated. Antibiotic treatment course: 7 to 10 days.
Primary Options
Acute Patient group
Treatment line
OR
Treatmenthide all

OR

OR


Infections should begin to respond within 48 hours. If there is no response after 48 hours, the patient should be re-assessed. Adolescents who have developed systemic infection should be treated parenterally (generally with vancomycin), if this has not already been used first-line. Alternatives include linezolid, tigecycline, or daptomycin. Treatment course: 10 to 14 days.
Primary Options 2nd

Secondary Options

OR

OR
daptomycin : 6 mg/kg intravenously once daily mastitis in neonates,
Acute Patient group
Treatment line
Treatmenthide all
infants, and children (<12 years)

intravenous anti-staphylococcal penicillin or first-generation cephalosporin plus supportive care
Neonates, infants, and children suspected to have mastitis should be referred to a paediatric specialist for management. They should generally be treated with parenteral antibiotics until bacteraemia can be ruled out. [25] If MRSA can be excluded by culture, initial antibiotic treatment should consist of an antistaphylococcal penicillin (e.g., nafcillin, oxacillin, or flucloxacillin, depending on availability) or a first-generation cephalosporin (e.g., cefazolin). Supportive measures include analgesia for pain relief if necessary and warm/cold compresses if tolerated. Antibiotic treatment course: 7 to 10 days
Primary Options
MRSA excluded by culture or not 1st prevalent in area and no penicillin allergy
flucloxacillin : infants and children: 25-50 mg/kg intravenously every 4-6 hours; consult specialist for guidance on neonatal doses
OR
nafcillin : infants and children: 50-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; consult specialist for guidance on neonatal doses
OR
oxacillin : infants and children: 100-200 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day; consult specialist for guidance on neonatal doses
OR
cefazolin : infants and children: 25-100 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 6 g/day; consult specialist for guidance on
Acute Patient group
Treatment line neonatal doses
Treatmenthide all
plus
[?]
The diagnosis and treatment will need to be reassessed, with adjustment made if there is no response to antibiotics within 48 hours. If initial treatment did not include an agent with activity against MRSA and there has been no response to antibiotics within 48 hours, the regimen should be broadened. Antibiotic therapy should be adjusted depending on the specific pathogen(s) isolated. For susceptible gram-negative pathogens, an aminoglycoside (e.g., gentamicin, tobramycin, or amikacin) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) should be included. Serum aminoglycoside should be monitored regularly according to local protocols to prevent nephrotoxicity and neurotoxicity.
MRSA confirmed by culture or prevalent 1st in area or penicillin allergy
Neonates, infants, and children suspected to have mastitis should be referred to a paediatric specialist for management. They should generally be treated with parenteral antibiotics until bacteraemia can be ruled out. [25] In cases where MRSA is isolated or suspected, and it is community-acquired, trimethoprim/sulfamethoxazole can be used in infants older than 2 months of age. Infants less than 2 months of age may be treated with clindamycin. Vancomycin is used first-line if the child is ill with systemic symptoms including fever, chills, and anorexia, or hospital-acquired MRSA is suspected. Supportive measures include analgesia for pain relief if necessary and warm/cold compresses if tolerated. Antibiotic treatment course: 7 to 10 days.
Primary Options
trimethoprim/sulfamethoxazole : children >2 months of
Acute Patient group
Treatment line
Treatmenthide all
age: 8-10 mg/kg/day intravenously/orally given in divided doses every 12 hours

More OR
clindamycin : infants and children: 20-40 mg/kg/day intravenously given in 3-4 divided doses, or 10-20 mg/kg/day orally given in 3-4 divided doses; consult specialist for guidance on neonatal doses
OR
vancomycin HCl : infants and children: 15 mg/kg intravenously every 8 hours; consult specialist for guidance on neonatal doses
plus
[?]
The diagnosis and treatment will need to be reassessed, with adjustment made if there is no response to antibiotics within 48 hours. Antibiotic therapy should be adjusted depending on the specific pathogen(s) isolated. For gram-negative pathogens an aminoglycoside (e.g., gentamicin, tobramycin, or amikacin) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) should be included.
breast abscess
intravenous or oral antibiotic with activity against methicillin-sensitive staphylococci plus supportive care
adult: MRSA excluded by culture 1st or not prevalent in area and no penicillin allergy
The patient with a breast abscess, which may or may not be associated with mastitis, requires antibiotic therapy. If MRSA can be excluded, a breast abscess can be treated with an intravenous or oral antibiotic that is active against methicillin-sensitive staphylococci. Supportive measures include analgesics if required. Antibiotic treatment course: 7 to 10 days.
Primary Options
Acute Patient group
Treatment line
Treatmenthide all

OR
dicloxacillin : 500 mg orally four times daily

OR
cefalexin : 500 mg orally three times daily

OR

OR

OR
flucloxacillin : 0.5 to 2 g intravenously every 6 hours

OR
oxacillin : 1-2 g intravenously every 4-6 hours

OR
nafcillin : 1-2 g intravenously every 4-6 hours

OR
cefazolin : 1-2 g intravenously every 8 hours

plus
[?]
The diagnosis and treatment will need to be reassessed, with adjustment made if there is no response to antibiotics within 48 hours. Antibiotic therapy should be adjusted depending on the specific pathogen(s) isolated. The antibiotic regimen may be broadened to cover MRSA. If gram-negative bacilli are isolated, a quinolone
Acute Patient group
Treatment line
Treatmenthide all
(e.g., levofloxacin) can be used, if the patient is not breastfeeding. Alternatively, a third-generation cephalosporin (e.g., ceftriaxone or cefotaxime) can be used for infection with gram-negative bacilli.
surgical intervention

adjunct
[?]
Surgical intervention is required for mature fluctuant abscesses. Needle aspiration (18- to 19-gauge needle) with or without ultrasound guidance can be used to drain an abscess. [53] [54] [55] [56] [57] [58] [59] Aspiration gives excellent palliation and cosmesis. Multiple aspirations over time (daily aspiration for 5 to 7 days) may be necessary for complete drainage, which can be followed by ultrasound if available. Incision and drainage should be reserved for patients in whom aspiration fails and/or for large abscesses (>5 cm in diameter).[B Evidence] Percutaneous catheter drainage has also been used with success.[C Evidence] Purulent material should be submitted for microbiology studies and cytological examination. Antibiotics should be continued for up to 10 days after drainage. If the abscess is <5 cm in diameter and there is no associated cellulitis, antibiotics may not be required. If the incision does not interfere with breastfeeding, a lactating mother can continue to nurse. If the incision does interfere with nursing on an affected breast, milk can be regularly removed with a breast pump.
adult: MRSA confirmed by culture 1st or prevalent in area or penicillin allergy
Where community-acquired MRSA (CA-MRSA) is suspected or confirmed, or in a patient with a penicillin allergy, trimethoprim/sulfamethoxazole, doxycycline, or clindamycin can be used. Mother should not continue to breastfeed on trimethoprim/sulfamethoxazole if the infant is younger than 2 months of age. Mother should not breastfeed at all if on doxycycline. Vancomycin can be used in more severe cases and
Acute Patient group
Treatment line
Treatmenthide all
in hospitalised patients where hospital-acquired MRSA is suspected. Alternatives, especially for patients exhibiting signs of systemic illness, include linezolid, tigecycline, and daptomycin. Supportive measures include analgesics if required. Antibiotic treatment course: 7 to 10 days.
Primary Options

OR

OR

OR
vancomycin HCl : 15 mg/kg intravenously every 12 hours

Secondary Options

OR

OR

re-assess diagnosis and treatment plus
[?]
The diagnosis and treatment will need to be reassessed, with adjustment made if there is no response to antibiotics within 48 hours. Antibiotic therapy should be adjusted depending
Acute Patient group
Treatment line
Treatmenthide all
on the specific pathogen(s) isolated. If gram-negative bacilli are isolated, a quinolone (e.g., levofloxacin) can be used, if the patient is not breastfeeding. Alternatively, a third-generation cephalosporin (e.g., ceftriaxone or cefotaxime) can be used for infection with gram-negative bacilli.

adjunct
[?]
Surgical intervention is required for mature fluctuant abscesses. Needle aspiration (18- to 19-gauge needle) with or without ultrasound guidance can be used to drain an abscess. [53] [54] [55] [56] [57] [58] [59] Aspiration gives excellent palliation and cosmesis. Multiple aspirations over time (daily aspiration for 5 to 7 days) may be necessary for complete drainage, which can be followed by ultrasound if available. Incision and drainage should be reserved for patients in whom aspiration fails and/or for large abscesses (>5 cm in diameter).[B Evidence] Percutaneous catheter drainage has also been used with success.[C Evidence] Purulent material should be submitted for microbiology studies and cytological examination. Antibiotics should be continued for up to 10 days after drainage. If the abscess is <5 cm in diameter and there is no associated cellulitis, antibiotics may not be required. If the incision does not interfere with breastfeeding, a lactating mother can continue to nurse. If the incision does interfere with nursing on an affected breast, milk can be regularly removed with a breast pump.
neonate, infant, or child: MRSA excluded by culture 1st or not prevalent in area and no penicillin allergy
antibiotic with activity against methicillin-sensitive staphylococci plus supportive care
If MRSA can be excluded, a breast abscess can be treated with an intravenous antibiotic that is active against methicillin-sensitive staphylococci. Duration of antibiotic treatment will depend on clinical response. Doxycycline may only be used in children >8
Acute Patient group
Treatment line

Treatmenthide all
years of age. Supportive measures include analgesics if required. Antibiotic treatment course: 7 to 10 days.
Primary Options
dicloxacillin : children <40 kg: 12.5 to 25 mg/kg/day orally given in 4 divided doses; children >40 kg: 125-250 mg every 6 hours for 7-10 days; use in neonates is not recommended
OR
flucloxacillin : children: 12.5 to 25 mg/kg orally four times daily; consult specialist for guidance on neonatal doses
OR
cefalexin : infants and children: 25-100 mg/kg/day orally given in 3-4 divided doses, maximum 4 g/day; use in neonates is not recommended
OR
doxycycline : children >8 years of age: 2.2 mg/kg orally once daily
OR
Secondary Options
flucloxacillin : infants and children: 25-50 mg/kg intravenously every 4-6 hours; consult specialist for guidance on neonatal doses
OR
oxacillin : infants and children: 50-200 mg/kg/day
Acute Patient group
Treatment line
Treatmenthide all
intravenously given in divided doses every 4-6 hours, maximum 12 g/day; consult specialist for guidance on neonatal doses
OR
nafcillin : infants and children: 100-200 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day; consult specialist for guidance on neonatal doses
OR
cefazolin : infants and children: 25-100 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 6 g/day; consult specialist for guidance on neonatal doses
plus
[?]
The diagnosis and treatment will need to be reassessed, with adjustment made if there is no response to antibiotics within 48 hours. Antibiotic therapy should be adjusted depending on the specific pathogen(s) isolated. If gram-negative bacilli are isolated, a thirdgeneration cephalosporin (e.g., ceftriaxone or cefotaxime) can be used. Vancomycin can be used in more severe cases.
adjunct
[?]
Surgical intervention is required for mature fluctuant abscesses. In a pre-pubertal child, care must be taken to avoid injury to the breast bud. For this reason, in neonates, needle aspiration is preferred and, if required, a small peripheral incision should be made.
neonate, infant, or child: MRSA 1st confirmed by culture or prevalent in area or penicillin allergy
Where community-acquired MRSA (CA-MRSA) is suspected or confirmed, or in a patient with a penicillin allergy, trimethoprim/sulfamethoxazole
Acute Patient group
Treatment line
Treatmenthide all
or clindamycin can be used. Doxycycline may only be used if the child is >8 years old. Vancomycin can be used in more severe cases and in hospitalised patients where hospital-acquired MRSA is suspected. Supportive measures include analgesics if required. Antibiotic treatment course: 7 to 10 days.
Primary Options
trimethoprim/sulfamethoxazole : children >2 months of age: 8-10 mg/kg/day intravenously/orally given in divided doses every 12 hours
More OR
doxycycline : children >8 years of age: 2.2 mg/kg orally once daily
OR
OR
vancomycin HCl : infants and children: 15 mg/kg intravenously every 8 hours; consult specialist for guidance on neonatal doses
plus
[?]
The diagnosis and treatment will need to be reassessed, with adjustment made if there is no response to antibiotics within 48 hours. Antibiotic therapy should be adjusted depending on the specific pathogen(s) isolated. If gram-negative bacilli are isolated, a thirdgeneration cephalosporin (e.g., ceftriaxone or cefotaxime) can be used.
Acute Patient group
Treatment line
Treatmenthide all
adjunct
[?]
Surgical intervention is required for mature fluctuant abscesses. In a pre-pubertal child, care must be taken to avoid injury to the breast bud. For this reason, in neonates, needle aspiration is preferred and, if required, a small peripheral incision should be made.
Ongoing Patient group
Treatment line
Treatmenthide all consideration of further surgical intervention
breast abscess post acute intervention
1st
After the acute phase has subsided, chronically infected tissue and the major lactiferous duct associated with the abscess leading to the nipple may need to be excised.[C Evidence]
re-assessment and treatment
recurrence of mastitis and/or breast abscess
1st

Recurrence may occur with delayed therapy, a short course of therapy, inappropriate therapy, and in Staphylococcus carriers. Recurrent mastitis or persistence of a mass after therapy may be due to a breast abscess or underlying breast lesion. Granulomatous mastitis has a high recurrence rate. Smoking cessation should also be encouraged to minimise the risk of recurrence.
Treatment approach
The goal of treatment for mastitis is to provide prompt and appropriate management to prevent complications such as a breast abscess. Neonatal/paediatric mastitis treatment is best managed by a paediatrician. Patients with a breast abscess are referred to a surgeon for definitive care. [44]
Lactational mastitis
Treatment includes: [45]

Antibiotic therapy Effective milk removal Warm compresses Symptomatic relief Supportive counselling.
In an early stage, when signs and symptoms of mastitis are not severe, or have not been present more than 12 to 24 hours, it may be possible to manage the condition without antibiotics. [46] [47] [48] Antibiotics are indicated for patients with:

Acute pain Severe symptoms or lasting more than 12 to 24 hours Fever Systemic infection Positive microbiology studies.
Since Staphylococcus aureus is the most common pathogen, antibiotics with activity against staphylococci should be used. In many regions, the majority of isolates are resistant to methicillin. If MRSA can be excluded by culture or if not prevalent in the area, initial antibiotics may include oral dicloxacillin, cloxacillin, or flucloxacillin (depending on availability) for 10 to 14 days. In areas where MRSA is common, or in penicillin-allergic patients, clindamycin or trimethoprim/sulfamethoxazole is indicated. Generally most of these patients are outpatients, and these antibiotics are indicated to treat community-acquired MRSA (CA-MRSA). These antibiotics would not be indicated if hospital-acquired MRSA was suspected. The mother should not continue to breastfeed while the infant is younger than 2 months old if trimethoprim/sulfamethoxazole is used. Doxycycline can also be used for CA-MRSA infections, during which time the mother should not breastfeed. Lactational mastitis due to CA-MRSA infection is frequently reported in women who are otherwise healthy and lack traditional risk factors for hospital-acquired MRSA. [CDC: postpartum mastitis and community-acquired methicillin-resistant Staphylococcus aureus] (external link) [12] Infections should begin to respond within 48 hours. If the infection is worsening despite oral therapy or if the infection is severe and occurs in a hospitalised patient, intravenous vancomycin can be used. This antibiotic covers both CA-MRSA and hospital-acquired MRSA. Other antibiotics with activity against MRSA, including linezolid, tigecycline, and daptomycin, can be used in refractory cases, but experience with these agents in treating mastitis is limited. They are expensive and information is lacking regarding levels in breast milk. Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities. Effective milk removal may involve continued frequent nursing (e.g., breastfeeding 8 to 12 times per day), breast pumping on the affected side if indicated, and/or massage if tolerated. Supportive measures should include:

Analgesia for pain relief if necessary (e.g., paracetamol, ibuprofen) Increased fluid intake
Warm and/or cold compresses Bed rest Supportive counselling.
Patients may require hospital admission for parenteral antibiotic therapy, pain management, and/or surgical intervention, particularly if they:

Are immunosuppressed Appear toxic (e.g., bacteraemia/sepsis is suspected) Are haemodynamically unstable Exhibit a rapidly progressive infection Fail outpatient antibiotic therapy.
When nipple candidiasis is diagnosed, both mother and infant must be treated simultaneously. For recurrent cases, cultures from the infant's and mother's oral cavities and nasopharynx are submitted to determine their staphylococcal carrier status. As an additional point, bromocriptine is not recommended in the management of this condition.
Non-lactational mastitis in adults

Initial treatment for infectious and non-infectious non-lactational mastitis involves appropriate antimicrobial therapy. Generally, even if the indications for antibiotics (as described above) are not met, patients are commenced on antibiotics at an early stage without any period of observation. It can be very difficult to differentiate between non-infectious and infectious non-lactational mastitis at this stage, so antibiotics are used in all cases. An isolated nipple infection can be treated with topical therapy (e.g., mupirocin 2% or a polymyxincontaining preparation). For infectious non-lactational mastitis:

Antibiotic therapy and indications for admission are identical to those outlined for lactational mastitis. Antifungal therapy (e.g., fluconazole) is indicated for deep fungal infections. TB of the breast requires 6 months of anti-TB therapy including 2 months with a 4-drug combination (e.g., ethambutol, rifampin, isoniazid, and pyrazinamide) followed by 4 months with a 2-drug combination (isoniazid and rifampin). [49] A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention. For post-operative wound infections, a surgeon should be consulted. Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body. Supportive measures should include analgesia for pain relief if necessary.
Treatment for non-infectious non-lactational mastitis:

Is initially the same as that for infectious mastitis, with antibiotic therapy. [2] [23] For granulomatous mastitis (idiopathic granulomatous inflammation), corticosteroids are the treatment of choice, and surgery is not necessary. Supportive measures should include analgesia for pain relief if necessary.
Neonatal/paediatric/adolescent mastitis
Neonates and infants suspected to have mastitis should be referred to a paediatric specialist for management. They should generally be treated with parenteral antibiotics until bacteraemia can be ruled out. If MRSA can be excluded by culture, initial antibiotic treatment should consist of a penicillin that is active against methicillin-sensitive staphylococci (e.g., nafcillin, oxacillin, or flucloxacillin, depending on availability), or a first-generation cephalosporin (e.g., cefazolin). In cases where MRSA is isolated or suspected, and it is community-acquired, clindamycin or, in infants older than 2 months of age, trimethoprim/sulfamethoxazole can be used. If the infection is worsening and in cases of MRSA in an ill child or a hospitalised child (where hospital-acquired MRSA is suspected), vancomycin should be used. Antibiotic therapy should be adjusted depending on the specific pathogen(s) isolated. For gram-negative pathogens an aminoglycoside (e.g., gentamicin, tobramycin, or amikacin) or third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) should be included. In adolescents, initial antibiotic treatment can usually be oral. Initial antibiotics for adolescents, if MRSA can be excluded, may include an oral penicillin (e.g., dicloxacillin, cloxacillin, or flucloxacillin, depending on availability) that is active against methicillin-sensitive staphylococci, for 10 to 14 days. In areas where MRSA is prevalent or suspected, and in cases of penicillin allergy, initial treatment should include clindamycin, trimethoprim/sulfamethoxazole, or doxycycline (the latter only in children >8 years of age). Generally most of these patients are outpatients, and these antibiotics are indicated to treat communityacquired MRSA (CA-MRSA). Infections should begin to respond within 48 hours. If there is no response after 48 hours, the patient should be re-assessed. If initial treatment did not include an agent with activity against MRSA, the regimen should be broadened. Adolescents with a systemic infection should be treated parenterally (generally with vancomycin). Also, adolescents with severe infection who are hospitalised should be treated with vancomycin to cover hospital-acquired MRSA. Alternatives include linezolid, tigecycline, or daptomycin. Supportive measures include analgesia for pain relief if necessary and warm/cold compresses if tolerated.
Refractory cases
In refractory cases, the following diagnoses should be considered:

Multiple and/or deep abscess Coexistent malignancy Underlying breast abnormality Fistula Fungal infection TB Atypical mycobacteria Other unusual infectious pathogen or multi-drug resistance Granulomatous mastitis.
An ultrasound should be performed looking for possible underlying abscess. A biopsy should be considered. Cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-
resistant pathogen. If a fistula is detected it needs to be excised (fistulectomy) along with its feeding duct. [50]
Breast abscess
The patient with a breast abscess, which may or may not be associated with mastitis, requires antibiotic therapy. Studies have found that breast abscesses in women admitted with puerperal mastitis were most commonly associated with community-acquired MRSA (CA-MRSA). [51] [52] If MRSA can be excluded, a breast abscess can be treated with an intravenous or oral antibiotic that is active against methicillin-sensitive staphylococci. In cases of suspected or confirmed CA-MRSA, or in a patient with a penicillin allergy, trimethoprim/sulfamethoxazole, doxycycline, or clindamycin can be used. Vancomycin may be used in more severe cases and in hospitalised patients where hospital-acquired MRSA is suspected. Alternatives in adults, especially for patients exhibiting signs of systemic illness, include linezolid (oral or intravenous), tigecycline (intravenous), and daptomycin (intravenous). If gram-negative bacilli are isolated, a quinolone can be used in adults if the patient is not breastfeeding. Alternatively, a third-generation cephalosporin (e.g., ceftriaxone or cefotaxime) can be used. For an early abscess presenting as an indurated mass, a course of antibiotics may suffice. For a mature abscess (e.g., fluctuant mass), surgical intervention along with antibiotics is indicated. Needle aspiration (18- to 19-gauge needle) with or without ultrasound guidance can be used to drain an abscess. [53] [54] [55] [56] [57] [58] [59] Aspiration gives excellent palliation and cosmesis. Multiple aspirations over time (daily aspiration for 5 to 7 days) may be necessary for complete drainage, which can be followed by ultrasound if available. Incision and drainage should be reserved for patients in whom aspiration fails and/or for large abscesses (>5 cm in diameter).[B Evidence] Percutaneous catheter drainage has also been used with success.[C Evidence] Purulent material should be submitted for microbiology studies and cytological examination. Antibiotics should be continued for up to 10 days after drainage. If the abscess is <5 cm in diameter, and there is no associated cellulitis, antibiotics may not be required. After the acute phase has subsided, chronically infected tissue and the major lactiferous duct associated with the abscess leading to the nipple may need to be excised.[C Evidence] If the incision does not interfere with breastfeeding, a lactating mother can continue to nurse. If the incision does interfere with nursing on an affected breast, milk can be regularly removed with a breast pump. In a pre-pubertal child, care must be taken to avoid injury to the breast bud. For this reason, in neonates, needle aspiration is preferred and, if required, a small peripheral incision should be made. Pain medication should be prescribed as necessary.
Recurrence of mastitis and/or breast abscess

May occur with delayed therapy, a short course of therapy, inappropriate therapy, and in Staphylococcus carriers. Recurrent mastitis or persistence of a mass after therapy may be due to a breast abscess or underlying breast lesion. Granulomatous mastitis has a high recurrence rate. Smoking cessation should also be encouraged to minimise the risk of recurrence.
Emerging treatments
Oxytocin nasal spray
This can be attempted in lactational mastitis to facilitate the letdown reflex and aid emptying of the breast. [26]
Vitamins
Vitamin E may help with mastitis. Supplements with retinol, vitamin A, and beta-carotene have not been shown to prevent subclinical mastitis, [2] and in a study in HIV-positive women, actually increased the risk of subclinical mastitis. [61]
Monitoring
Following therapy, patients should be re-examined (e.g., using ultrasonography) for development of a potential abscess that may need to be drained. An inflammatory mass that does not respond to therapy should be biopsied to exclude underlying carcinoma or an unusual infection. For women >40 years of age, breast imaging studies, such as mammography, should be performed after resolution of the acute process to exclude unsuspected underlying breast cancer.
Patient Instructions
Patients should seek medical help if their symptoms do not improve within 48 hours after antibiotic therapy for mastitis, or if a tender breast lump develops that is not relieved by breastfeeding. They should contact a paediatrician if their nursing child shows signs of illness or develops a nappy rash while the mother is taking antibiotics. Patients can be reassured that a breast infection does not increase the chances of developing breast cancer. [14] On-line patient information from recommended sources may be helpful for breastfeeding mothers. [NHS Choices. Mastitis (breastfeeding).] (external link) [NHS Choices. Breastfeeding guide.] (external link) Information concerning non-lactational mastitis and breast abscess is also available. [NHS Choices. Mastitis (non-breastfeeding).] (external link) [NHS Choices. Breast abscess.] (external link)
Complications
Complicationhide all cessation of breastfeeding Timeframe Likelihood short term medium
The development of mastitis may lead to the cessation of breastfeeding. However, an abrupt cessation of breastfeeding may exacerbate the symptoms of mastitis, and there is an increased risk of breast abscess. Effective treatment and support from healthcare workers and family are important. [63]
abscess (complicating mastitis) short term low
Less than 10% of patients with mastitis are likely to develop a breast abscess.
sepsis
see our comprehensive coverage of Sepsis Any breast infection may be associated with bacteraemia, particularly in very young and immunosuppressed patients.
scarring
short term low
Breast infection, including an abscess that is adequately treated, is unlikely to cause significant breast scarring.
long term low
Surgical intervention other than needle aspiration may cause a postoperative scar. Recurrent infections, TB, and granulomatous mastitis can cause significant breast deformity.
functional mastectomy long term low
This refers to a breast that is unable to effectively lactate as a complication of prior tissue destruction from infection or treatment.
breast hypoplasia long term low
Damage to the infant breast bud from scarring and/or surgical intervention may cause subsequent breast asymmetry and/or hypoplasia.
necrotising fasciitis
see our comprehensive coverage of Necrotising fasciitis Mastitis may be the initiating event for necrotising fasciitis, particularly in childhood. [62]
extra-mammary skin infection
variable
low
variable
low
Patients with Staphylococcus aureus mastitis are at risk for subsequent skin
infections at extra-mammary sites.

fistula
Spontaneous rupture of an abscess can lead to a draining sinus with a resulting fistula. A mammary fistula occurs in 1% to 2% of women. [6]
Prognosis
When treated promptly and appropriately, most breast infections including abscess will resolve without serious complications. Most patients will have resolution of mastitis after 2 to 3 days of appropriate antibiotic therapy.
Breastfeeding
Most patients with breast infection can continue to breastfeed, with the exception of those who are HIV infected. [1] Nursing mothers should not breastfeed if they are being treated with trimethoprim/sulfamethoxazole and the infant is less than 2 months of age. Doxycycline is contraindicated in breastfeeding women.
Recurrence
Mastitis may recur with delayed therapy, inappropriate therapy, uncorrected poor breastfeeding technique, nipple candidiasis, an underlying breast condition, and in Staphylococcus carriers. Recurrent mastitis or persistence of a mass after therapy may be due to a breast abscess or underlying breast lesion. Granulomatous mastitis has a high (up to 50%) recurrence rate.

Breast Abscess

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Breast Abscess

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1st tests to order

non-lactational mastitis in adults and adolescents

mastitis in neonates, infants, and children (<12 years)

consideration of further surgical intervention

recurrence of mastitis and/or breast abscess

re-assessment and treatment

History & examination

breast pain (common)

decreased milk outflow (common)

Milk stasis may be associated with the development of mastitis.

breast warmth (common)

breast tenderness (common)

breast firmness (common)

breast swelling (common)

breast erythema (common)

breast mass (uncommon)

A fistula is usually associated with a draining sinus from an underlying abscess.

Other diagnostic factorshide all

nipple discharge (uncommon)

nipple inversion/retraction (uncommon)

Infrequently seen with mastitis.

extra-mammary skin lesions (uncommon)

Risk factorshide all

women 15 to 45 years of age

infants <2 months of age

poor breastfeeding technique

prolonged mastitis (breast abscess)

Prolonged mastitis may be associated with breast abscess formation.

prior breast abscess (breast abscess)

shaving or plucking areola hair

anatomical breast defect, mammoplasty, or scar

other underlying breast condition

Particularly breast cancer.

Staphylococcus aureus carrier

Weak hospital admission

overabundant milk supply

post-maturity (breast abscess)

May increase the risk of lactational mastitis. [1]

Believed to promote milk stasis. [1]

antifungal nipple cream

fibrocystic breast disease

May interfere with milk flow.

vaginal manipulation (breast abscess)

purulent fluid indicates a breast abscess

if present: infection and/or malignancy demonstrated

if present: infection, granulomatous inflammation, or malignancy demonstrated.

Tests to considerhide all

Test pregnancy test may be positive

If mastitis develops unexpectedly, such as in an adolescent, a pregnancy test should be considered.

positive culture indicates systemic infection

For recurrent cases of lactational mastitis, cultures

normal; leukocytosis with infection; neutropenia with immunosuppression

often positive with active TB

Usually becomes clinically apparent as breastfeeding continues.

Usually becomes clinically apparent as breastfeeding continues.

Primary invasive breast cancer

Presents typically as a non-tender, rubbery, well-circumscribed, and mobile mass.

Mammography and a microbiology work-up are usually negative.

Systemic lupus erythematosus

Patients may have fever, chills,

Tests are not necessary.

Neonatal breast hypertrophy

Tests are not necessary.