Clinical experience with aspiration of breast abscesses based on size and etiology at an academic medical center

Analysis of relevant factors influencing size of breast abscess cavity during lactation: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate risk factors for the severity of breast abscess during lactation.

METHODS

A cross-sectional study was conducted using data from the Questionnaire survey of breast abscess patients. According to whether the maximum abscess diameter > 5 cm, the patients were divided into two groups for univariate and multivariate regression analysis.

RESULTS

1805 valid questionnaires were included. Univariate and Binary logistic regression analysis demonstrated that low education (OR = 1.5, 95% CI 1.1-2.0, P = 0.005), non-exclusive breastfeeding (OR = 0.7, 95% CI 0.6-0.9, P = 0.004), fever > 37.5 ℃ (OR = 0.7, 95% CI 0.6-0.9, P = 0.003), flat or inverted nipples (OR = 0.7, 95% CI 0.6-0.9, P = 0.005), antibiotic used (OR = 0.7, 95% CI 0.6-0.9, P = 0.006), and non-medical massage (OR = 0.3, 95% CI 0.2-0.4, P < 0.001) were the effective independent influencing factors for the maximum breast abscess diameter > 5 cm.

CONCLUSION

Low education, non-exclusive breastfeeding, fever > 37.5 ℃, inverted or flat nipples, antibiotic used, and non-medical massage history have adverse effects on the severity of breast abscess during lactation.

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

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

Maintaining Breastfeeding During the Treatment of Breast Abscesses Is Not Contraindicated

Background: World Health Organization guidelines recommend maintaining breastfeeding if a woman develops breast abscess, because of benefits to her recovery and the infant's health. However, clinical staff recommend weaning to promote faster recovery from the abscess. The purpose of this study was to determine whether maintaining breastfeeding after development of a breast abscess has any influence on the resolution of the breast abscess. Methods: The records of 212 patients who were breastfeeding and developed breast abscess treated at Guangzhou Women and Children's Medical Center from January 2018 to December 2019 were retrospectively reviewed. Patients were divided into two groups: those who maintained breastfeeding (study group) and those who stopped breastfeeding (control group). Results: There were 139 patients in study group and 73 patients in the control group. Baseline characteristics were similar between the two groups. The time to cure in the study group and in the control group was 7.20 ± 2.21 days and 7.01 ± 2.39 days, respectively (t = 0.579, p = 0.563). Common complications were milk fistula and galactocele, and the frequency of both was similar between the two groups (milk fistula: 7.9% versus 8.2%, respectively; χ² = 0.006, p = 0.938; galactocele: 8.6% versus 9.6%, respectively; χ² = 0.054, p = 0.817). There was no significant difference in the recurrence rates between the two groups (5.0% versus 2.7%; χ² = 0.184, p = 0.668). Conclusion: Maintaining breastfeeding during treatment of breast abscess does not affect the outcome of treatment provided, on condition that the abscess is treated appropriately.

Breast Imaging After Dark

Patients may present to the emergency department with breast complaints due to traumatic or nontraumatic changes in the breast. Benign and malignant breast pathologies may mimic each other both in clinical presentation and imaging appearance. A complex cystic and solid mass seen on ultrasound in a patient with a palpable mass can represent breast cancer, abscess, or hematoma. A unilateral swollen breast may result from inflammatory breast cancer, mastitis, or other benign etiologies; correlation with clinical history, physical exam, and close follow-up are required to ensure complete resolution of symptoms. Uncommon breast entities such as granulomatous mastitis and breast implant-associated anaplastic large-cell lymphoma may cause changes in the appearance of the breast that prompt a patient to seek initial evaluation in the emergency department. Imaging evaluation of the breast in the emergency department is limited, and it is important that patients with a breast complaint be referred to a dedicated breast center for complete evaluation at an appropriate time interval after their discharge from the emergency department.

Characterization of Pediatric Breast Abscesses and Optimal Treatment: A Retrospective Analysis

BACKGROUND

Literature on pediatric breast abscesses is sparse; therefore, treatment is based on adult literature which has shifted from incision and drainage (I&D) to needle aspiration. However, children may require different treatment due to different risk factors and the presence of a developing breast bud. We sought to characterize pediatric breast abscesses and compare outcomes.

MATERIALS AND METHODS

A retrospective review of patients presenting with a primary breast abscess from January 2008 to December 2018 was conducted. Primary outcome was persistent disease. Antibiotic utilization, treatment required, and risk factors for abscess and recurrence were also assessed. A follow-up survey regarding scarring, deformity, and further procedures was administered. Fisher's exact and Kruskal-Wallis tests for group comparisons and multivariable regression to determine associations with recurrence were performed.

RESULTS

Ninety-six patients were included. The median age was 12.8 y [IQR 4.9, 14.3], 81% were women, and 51% were African-American. Most commonly, patients were treated with antibiotics alone (47%), followed by I&D (27%), and aspiration (26%). Twelve patients (13%) had persistent disease. There was no difference in demographic or clinical characteristics between those with persistent disease and those who responded to initial treatment. The success rates of primary treatment were 80% with antibiotics alone, 90% with aspiration, and 96% with I&D (P = 0.35). The median time to follow-up survey was 6.5 y [IQR 4.4, 8.5]. Four patients who underwent I&D initially reported significant scarring.

CONCLUSIONS

Treatment modality was not associated with persistent disease. A trial of antibiotics alone may be considered to minimize the risk of breast bud damage and adverse cosmetic outcomes with invasive intervention.

A Systematic Review of Milk Fistula in Nursing Mothers: Modifying the Perspective Toward Maintenance of Breastfeeding

Introduction

Milk fistula is rare, and cessation of nursing has been recommended for treatment. We performed a comprehensive review of all existing literature to explore the causes of milk fistulae and the necessity of discontinuing breastfeeding, and mention our recommendations given our present practice.

Method

Google Scholar, Pubmed, Ovid Medline, and Scopus were thoroughly investigated by using relevant keywords. After screening by reading titles, abstracts, and full texts of returned studies, pertinent articles were included and data extracted.

Results

Seventeen studies including 27 cases were included. Lactation ceased in 16 patients, but this was generally done without awaiting results of conservative management.

Conclusion

We recommend measures for preventing milk fistulae, conservative measures for treatment, and continuation of breastfeeding throughout the process until healing occurs.

Zuska's breast disease: Breast imaging findings and histopathologic overview

Zuska's disease describes the clinical condition of recurrent central or periareolar nonpuerperal abscesses associated with lactiferous fistulas. Pathogenesis involves the occlusion of an abnormal duct through an epithelial desquamation process that causes ductal dilatation, stasis of secretions, and periductal inflammation. Patients with Zuska's disease may develop chronic draining sinuses near the areola from lactiferous ducts fistula; therefore, the underlying abnormal duct system must be located and excised for proper treatment. Zuska's disease is often misdiagnosed and mistreated and is associated with significant morbidity, including the recurrence of abscess and cutaneous fistula formation. This case series aimed to help clinicians investigate and manage this disorder. The clinical and imaging findings, histopathologic correlation, and treatment of Zuska's disease are discussed.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

Abscess Drainage with or Without Antibiotics in Lactational Breast Abscess: Study Protocol for a Randomized Controlled Trial

Background

Lactational breast abscess, a complication from lactational mastitis, is a common cause of breastfeeding discontinuation. No consensus has been reached regarding the necessity of antibiotics in this disease. The purpose of this trial is to determine if surgical drainage is non-inferior to drainage together with a standard course of antibiotics, in the treatment of lactational breast abscess.

Methods

Breastfeeding females with breast abscess from 18 to 50 years old are eligible for study inclusion. An expected number of 306 patients will be randomly allocated in parallel to the intervention arm (simple drainage without antibiotics) or the control arm (abscess drainage with standard 5-day-course of antibiotics). The primary outcomes include the time to resolution of breast abscess and disease recurrence rate. Secondary outcomes of interests are 3-day-improvement proportion, rate of continuing breastfeeding, treatment failure rate, procedural-related complications, and length of hospital stay. An expected non-inferiority margin for the difference in the primary outcome of interest is set at 1 day, on the basis of a one-sided 97.5% confidence interval.

Discussion

This trial will provide first-hand evidence on whether simple abscess drainage is non-inferior to drainage together with a standard course of antibiotics, in lactational mothers with breast abscess. The indication of antibiotic prophylaxis could be revised if non-inferiority is set up, and guidelines for lactational breast abscess require amendments correspondingly.

Trial Registration

This study has been registered in the Chinese Clinical Trial Registry, and the trial registration number is ChiCTR1900024008.

Breast infections - Microbiology and treatment in an era of antibiotic resistance

INTRODUCTION

Primary breast abscesses occur in <1% of non-lactating women, rising to 11% in women with lactational mastitis. In patients undergoing breast cancer surgery, the inflammatory response to post-operative surgical site infection (SSI) has been implicated in recurrence. Anti-microbial resistance increasingly hampers treatment in each group.

AIMS

Describe the demographic and predisposing characteristics of patients with primary breast abscesses and secondary infections, identify the microbial and antimicrobial patterns and formulate an evidence-based protocol for treating breast infections.

METHODS

Retrospective cohort study of all breast infections (primary and post-operative) treated at UHL from 2014 to 2017. Data collected from microbiology databases and patient records was analysed using Minitab V18.

RESULTS

537 cultures from 108 patients were analysed. 47 (43.5%) had primary abscesses, 12 (11.1%) were lactational and 49 (45.4%) were post-operative SSI. For primary infections, the mean age was 41.9 (±12.2) and reinfection rate 33%. For SSIs the mean age was 51.8 (±14.52) and reinfection rate 11.8%. Overall, 29.3% were smokers, 6.4% diabetic and 2.9% pregnant. 60 (43%) patients required radiological drainage and 2 (1%) surgical drainage. 57.5% had mixed growth. The most common isolate was Staphylococcus aureus; cultured in 16.7% of primary abscesses and 24% of SSIs. 13 empiric antibiotic regimes were prescribed before 26.4% of patients changed to 12 different targeted regimes.

CONCLUSION

Breast infections are frequently polymicrobial with a wide variety of organisms isolated, suggesting the need for broad spectrum coverage until culture results become available. Based on our local culture results, the addition of clindamycin to flucloxacillin would provide excellent empiric coverage for all categories of breast infection. An evidence-based treatment guideline is required and should be formulated in close collaboration with microbiology specialists.

Validation of the American Association for the Surgery of Trauma's emergency general surgery breast infection grading system

BACKGROUND

The American Association for the Surgery of Trauma (AAST) developed emergency general surgery (EGS) grading systems for multiple diseases to standardize classification of disease severity. The grading system for breast infections has not been validated. We aimed to validate the AAST breast infection grading system.

METHODS

Multi-institutional retrospective review of all adult patients with a breast infection diagnosis at Mayo Clinic Rochester 1/2015-10/2015 and Pietermaritzburg South African Hospital 1/2010-4/2016 was performed. AAST EGS grades were assigned by two independent reviewers. Inter-rater reliability was measured using the agreement statistic (kappa). Final AAST grade was correlated with patient and treatment factors using Pearson's correlation coefficient.

RESULTS

Two hundred twenty-five patients were identified: grade I (n = 152, 67.6%), II (n = 44, 19.6%), III (n = 25, 11.1%), IV (n = 0, 0.0%), and V (n = 4, 1.8%). At Mayo Clinic Rochester, AAST grades ranged from I-III. The kappa was 1.0, demonstrating 100% agreement between reviewers. Within the South African patients, grades included II, III, and V, with a kappa of 0.34, due to issues of the grading system application to this patient population. Treatment received correlated with AAST grade; less severe breast infections (grade I-II) received more oral antibiotics (correlation [-0.23, P = 0.0004]), however, higher AAST grades (III) received more intravenous antibiotics (correlation 0.29, P <0.0001).

CONCLUSIONS

The AAST EGS breast infection grading system demonstrates reliability and ease for disease classification, and correlates with required treatment, in patients presenting with low-to-moderate severity infections at an academic medical center; however, it needs further refinement before being applicable to patients with more severe disease presenting for treatment in low-/middle-income countries.

Predictors of outcomes in managing breast abscesses-A large retrospective single-center analysis

We have retrospectively examined a wide range of clinical characteristics, sonographic features, microbiology, and antibiotic regimens in patients with breast abscesses to seek predictive features related to outcome. Because consensus for optimal treatment of breast abscesses has moved toward minimally invasive management using single or repeated needle aspiration (ASP) coupled with adjuvant antibiotics, we assessed whether any factors correlate with the need for repeat procedures by analyzing the number of ASPs and/or surgical incision and drainage (I&D) per abscess. We examined 127 abscesses in 114 patients from a single urban public hospital, and among clinical characteristics, we found that only smoking history (P = .021) and the presence of nipple rings (P = .005) were associated with greater likelihood of necessitating repeat for abscess resolution procedures. Neither diabetes, lactational status, and HIV nor ultrasound features imaging of an abscess including size >3 cm, multiloculation, rind thickness, or central vs peripheral location were correlated with the need for a repeat procedure. Likewise, no specific micro-organisms predicted a greater likelihood of requiring repeat procedures, and no specific initial antibiotic regimen (gram-positive and/or gram-negative or multiresistance coverage) impacted clinical outcomes. Our data indicate that no specific imaging abscess characteristics, type of micro-organism, or initial choice of antibiotics affect outcomes, and therefore, these features should not preclude attempts at conventional therapy by repeated aspiration and antibiotic treatment. While a smoking history and presence of a nipple ring may increase the risk of a prolonged course, the decision to change antibiotics or repeat aspiration should rely instead on clinical evaluation and judgment by experienced physicians.

Comparison of needle aspiration and vacuum-assisted biopsy in the ultrasound-guided drainage of lactational breast abscesses

Purpose:

The purpose of this study was to compare needle aspiration and vacuum-assistedbiopsy in the ultrasound-guided treatment of lactational breast abscesses.

Methods:

Between January 2005 and December 2014, a total of 74 patients presented withlactational breast abscesses. Thirty of these patients underwent treatment with antibioticsalone, while the remaining 44 lactating women with breast abscesses were treated withneedle aspiration (n=25) or vacuum-assisted biopsy (n=19). Age, duration of lactation, abscess diameter, pus culture results, the number of interventions, the healing time, and the cure rate were reviewed and compared between these two groups. The Student’s t test and the chi-square test were used to compare the variables.

Results:

No significant difference was found in the cure rate between the needle aspirationgroup (22/25, 88%) and the vacuum-assisted biopsy group (18/19, 94.7%) (P=0.441). However, the mean healing time was significantly shorter in the vacuum-assisted biopsy group (6.7 days) than in the needle aspiration group (9.0 days) (P=0.001).

Conclusion:

Vacuum-assisted biopsy is a viable option for the management of lactational breast abscesses and was found to lead to a shorter healing time than needle aspiration. However, further study is necessary to establish the clinical efficacy of vacuum-assisted biopsy in the management of lactational breast abscesses.

Treatments for breast abscesses in breastfeeding women

BACKGROUND

The benefits of breastfeeding are well known, and the World Health Organization recommends exclusive breastfeeding for the first six months of life and continuing breastfeeding to age two. However, many women stop breastfeeding due to lactational breast abscesses. A breast abscess is a localised accumulation of infected fluid in breast tissue. Abscesses are commonly treated with antibiotics, incision and drainage (I&D) or ultrasound-guided needle aspiration, but there is no consensus on the optimal treatment.

OBJECTIVES

To assess the effects of different treatments for the management of breast abscesses in breastfeeding women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trial Register (27 February 2015). In addition we searched African Journals Online (27 February 2015), Google Scholar (27 February 2015), ProQuest Dissertations and Theses Databases (27 February 2015) and the WHO International Clinical Trials Registry Platform (ICTRP) search portal (27 February 2015). We also checked reference lists of retrieved studies and contacted experts in the field as well as relevant pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating any intervention for treating lactational breast abscesses compared with any other intervention. Studies published in abstract form, quasi-RCTs and cluster-RCTs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy.

MAIN RESULTS

We included six studies. Overall, trials had an unclear risk of bias for most domains due to poor reporting. Two studies did not stratify data for lactational and non-lactational breast abscesses, and these studies do not contribute to the results. This review is based on data from four studies involving 325 women. Needle aspiration (with and without ultrasound guidance) versus incision and drainage (I&D) Mean time (days) to complete resolution of breast abscess (three studies) - there was substantial heterogeneity among these data (Tau(2) = 47.63, I(2) = 97%) and a clear difference between subgroups (with or without ultrasound guidance; Chi(2) = 56.88, I(2) = 98.2%, P = < 0.00001). We did not pool these data in a meta-analysis. Two studies excluded women who had treatment failure when they calculated the mean time to complete resolution. One study found that the time to complete resolution of breast abscess favoured needle aspiration over I&D (mean difference (MD) -6.07; 95% confidence interval (CI) -7.81 to -4.33; n = 36), but excluded 9/22 (41%) women in the needle aspiration group due to treatment failure. Another study reported faster resolution in the needle aspiration group (MD -17.80; 95% CI -21.27 to -14.33; n = 64) but excluded 6/35 (17%) women in the needle aspiration group due to treatment failure. A third study also reported that needle aspiration was associated with a shorter time to complete resolution of breast abscess (MD -16.00; 95%CI -18.73 to -13.27; n = 60); however, the authors did not indicate the number of women who were lost to follow-up for either group, and it is unclear how many women contributed to this result. Considering the limitations of the available data, we do not consider the results to be informative. Continuation of breastfeeding, after treatment (success): results favoured the needle aspiration group, but we did not pool data from the two studies because of substantial unexplained heterogeneity (I(2) = 97%). One study reported that women in the needle aspiration group were more likely to continue breastfeeding (risk ratio (RR) 2.89; 95% CI 1.64 to 5.08; n = 60), whereas the other study found no clear difference (RR 1.09; 95% CI 0.97 to 1.22 n = 70). Treatment failure was more common among women treated with needle aspiration compared to those who underwent I&D (RR 16.12; 95% CI 2.21 to 117.73; two studies, n = 115, low quality evidence). In one study, treatment with needle aspiration failed in 9/22 women who subsequently underwent I&D to treat their breast abscess. In another study, treatment with needle aspiration failed in 6/35 women, who subsequently underwent I&D. All abscesses in the I&D group were successfully treated.The included studies provided limited data for the review's secondary outcomes. No data were reported for adverse events. One study (60 women) reported that women in the needle aspiration group were more satisfied with their treatment than women who received I&D to treat their breast abscesses. Incision and drainage (I&D) with or without antibioticsOne study (150 women) compared the value of adding a broad-spectrum cephalosporin (single dose or a course of treatment) to women who underwent I&D for breast abscesses.The mean time to resolution of breast abscess was reported as being similar in all groups (although women with infection were excluded). Mean time to resolution for women who received a course of antibiotics was reported as 7.3 days, 6.9 days for women who received a single dose of antibiotics and 7.4 days for women who did not receive antibiotics. Standard deviations, P values and CIs were not reported and prevented further analysis. No data were reported for any continuation of breastfeeding after treatment (success). For treatment failure, there was no clear difference between the groups of women who received antibiotics (either a single dose or a course of antibiotics) and those who did not (RR 1.00; 95% CI 0.36 to 2.76).Included studies rarely reported this review's secondary outcomes (including adverse events). For post-operative complications/morbidity, there was no difference in the risk of wound infections between the antibiotics and no antibiotics groups (RR 0.58; 95% CI 0.29 to 1.17), irrespective of whether women received a single dose or a course of antibiotics.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether needle aspiration is a more effective option to I&D for lactational breast abscesses, or whether an antibiotic should be routinely added to women undergoing I&D for lactational breast abscesses. We graded the evidence for the primary outcome of treatment failure as low quality, with downgrading based on including small studies with few events and unclear risk of bias.