Neonatal mastitis

Breast abscess in two Nepalese newborns: An unusual series

Background

Breast abscess in newborns is an exceedingly rare pyogenic inflammation that usually starts as mastitis neonatorum. Although mastitis can respond to antibiotic therapy in the initial stages, once advanced into a purulent collection, decompression may be indicated either in the form of needle aspiration or even surgical drainage. We present two newborns with breast abscesses managed surgically with successful outcomes.

Case presentation

Case 1: A 13-day-old boy presented with swelling and redness over the left breast for a day. Local examination revealed a warm, indurated swelling with redness and fluctuation. Needle aspiration confirmed pus. Intravenous (IV) antibiotics were started right away followed by pus drainage, the culture of which yielded Methicillin-Sensitive Staphylococcus aureus (MSSA). Regular wound care subsequently resulted in complete recovery.

Case 2: A 15-day-old boy presented with swelling, redness and milky discharge from the right breast for two days. The swelling was erythematous, tender and indurated but not cystic or fluctuant. Ultrasonogram was suggestive of an abscess. Once again, IV antibiotics were administered followed by drainage. Pus yielded MSSA. Following regular wound dressings, satisfactory healing was achieved.

Conclusion

Neonatal mastitis and breast abscess are uncommon. Early recognition followed by appropriate antibiotic therapy and drainage of the abscess is the mainstay of treatment.

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Neonatal mastitis and breast abscess are fairly uncommon.

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Breast abscess, an exceedingly rare pyogenic inflammation, starts as mastitis neonatorum.

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Clinical improvement is aided by adequate antibiotic coverage and needle aspiration or surgical drainage of pus.

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Prompt recognition and management are paramount to avoid complications.

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Newborns with breast abscesses are managed surgically with successful outcomes.

Neonatal Mastitis and Concurrent Serious Bacterial Infection

OBJECTIVES

Describe the clinical presentation, prevalence, and outcomes of concurrent serious bacterial infection (SBI) among infants with mastitis.

METHODS

Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants aged ≤90 days with mastitis who were seen in the emergency department between January 1, 2008, and December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized.

RESULTS

Among 657 infants (median age 21 days), 641 (98%) were well appearing, 138 (21%) had history of fever at home or in the emergency department, and 63 (10%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 581 (88%), 274 (42%), and 216 (33%) infants, respectively. Pathogens grew in 0.3% (95% confidence interval [CI] 0.04-1.2) of blood, 1.1% (95% CI 0.2-3.2) of urine, and 0.4% (95% CI 0.01-2.5) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 335 (51%) infants, with 77% (95% CI 72-81) growing a pathogen, most commonly methicillin-resistant Staphylococcus aureus (54%), followed by methicillin-susceptible S aureus (29%), and unspecified S aureus (8%). A total of 591 (90%) infants were admitted to the hospital, with 22 (3.7%) admitted to an ICU. Overall, 10 (1.5% [95% CI 0.7-2.8]) had sepsis or shock, and 2 (0.3% [95% CI 0.04-1.1]) had severe cellulitis or necrotizing soft tissue infection. None received vasopressors or endotracheal intubation. There were no deaths.

CONCLUSIONS

In this multicenter cohort, mild localized disease was typical of neonatal mastitis. SBI and adverse outcomes were rare. Evaluation for SBI is likely unnecessary in most afebrile, well-appearing infants with mastitis.

Acinetobacter baumannii neonatal mastitis: a case report

Introduction

Neonatal mastitis is a rare infection. When it does occur, infants younger than 2 months of age are typically affected and the majority of cases are caused by Staphylococcus aureus. We present the first reported case of neonatal mastitis caused by Acinetobacter baumannii, an unusual organism for this type of infection.

Case presentation

A 15-day-old full-term Caucasian male neonate presented to our emergency room following fever at home and was admitted for routine neonatal sepsis evaluation. After admission, he developed purulent drainage from his right nipple, was diagnosed with mastitis, and was started on empiric therapy with clindamycin and cefotaxime with presumed coverage for S. aureus. Drainage culture identified pan-susceptible Acinetobacter baumannii/haemolyticus and antibiotic therapy was changed to ceftazidime. He was discharged after 5 days of ceftazidime with complete resolution of his symptoms.

Conclusions

This case illustrates the importance of obtaining drainage cultures in mastitis cases because of the possibility of organisms besides S. aureus causing infection. Acinetobacter baumannii is considered part of the normal human flora and is associated with serious infections in intensive care units. This is the first case report describing Acinetobacter baumannii as an etiologic agent of neonatal mastitis and highlights the importance of including unusual organisms in the differential for infectious etiologies for general practitioners.

Evaluation and treatment of mastitis in infants

We reviewed cases of mastitis in infants treated at Children's Healthcare of Atlanta from 2005 to 2011. Among infants with breast cultures, Staphylococcus aureus was the most common cause. No infant with a positive breast culture had a concordant positive culture elsewhere. Our findings argue that urine, blood and spinal fluid cultures are unnecessary in well-appearing afebrile infants with mastitis.

Neonatal mastitis: controversies in management

Objective:

To document the range of presentations, extent of investigations, and treatment choices of ‘physicians treating’ neonates with mastitis seen over a 9-year period at a tertiary care pediatric hospital.

Materials and Methods:

An email survey was sent to Emergency Department (ED) staff and fellows asking them how they would treat a well-looking neonate with localized mastitis. Secondly, a retrospective chart review of neonates presenting to the ED with a diagnosis of neonatal mastitis or breast engorgement from July 2000 to December 2009 was conducted to assess how such patients were actually treated.

Results:

46/107 surveys were returned, with a wide discrepancy in how clinicians would treat neonatal mastitis: 4.3% would perform a full sepsis work up, including lumbar puncture, followed by IV antibiotics and hospital admission; 28% chose discharge on oral antibiotics; and 28% suggested admission only if blood work was abnormal. From the chart review, 33 neonates were diagnosed with possible neonatal mastitis over a 9-year period: 12 met the inclusion criteria. Of these, 8 (66%) were admitted and treated with intravenous antibiotics, 2 (16.6%) were treated with oral antibiotics, and 2 (16.6%) did not receive antibiotics. None of the 12 patients had lumbar puncture performed.

Conclusion:

There is significant disagreement among clinicians regarding the best way to treat the well-looking neonate with localized mastitis. Most elect to perform blood tests and start treatment with IV antibiotics with good Staphylococcus aureus coverage, followed by oral antibiotics if cultures are negative.

Evaluation, management, and outcome of focal bacterial infections (FBIs) in nontoxic infants under two months of age

BACKGROUND

Well-appearing young infants with focal bacterial infections present to the emergency department (ED) and are often admitted for a sepsis evaluation of blood, urine, and spinal fluid. However, the risk of concomitant systemic infections (CSI) in this population is not well reported, specifically comparing febrile to afebrile infants. We hypothesized that afebrile, well-appearing infants under two months of age with a defined focal bacterial infection on exam have a very low risk of CSI.

METHODS

This retrospective study was conducted at an urban, academic, tertiary care pediatric hospital ED on patients seen from January 2000-December 2005. Eligible infants were less than 60 days of age, well-appearing on exam, and with normal-for-age vital signs who presented with a focal bacterial infection on exam. Exclusion criteria included immunodeficiency, indwelling catheter, previous admission for bacterial infection, or current use of systemic antibiotics. Main study outcome was risk of CSI in febrile and afebrile groups.

RESULTS

One hundred ninety seven patients were included in the study population. Of these, 39 were febrile and 158 were afebrile. Four patients had a documented CSI: one case of S. pneumoniae bacteremia and three cases of E. coli urinary tract infection. Of these 4 infants, 3 were febrile (7.7% CSI risk) and 1 was afebrile (0.6%). Febrile infants had a significantly higher risk of CSI (OR 13.1, 95% CI 1.3, 129.5).

CONCLUSIONS

CSI is very uncommon in afebrile, well-appearing infants under 60 days of age with a focal bacterial infection.

Sonographic features of neonatal mastitis and breast abscess

BACKGROUND

Neonatal mastitis and neonatal breast abscess are uncommon. Although well described in the pediatric and surgical literature, there is a paucity of reports describing their sonographic features.

OBJECTIVE

To describe and illustrate the sonographic features of neonatal mastitis and neonatal breast abscess.

MATERIALS AND METHODS

We reviewed the medical database of a large children's health-care center from 2000 through 2008 for patients presenting in the first 8 weeks of life with mastitis. The findings were correlated with clinical presentation and course, laboratory findings and clinical outcome.

RESULTS

Four neonates (three girls and one boy) presented with mastitis. They all had prominent breast buds on the affected side with poorly defined margins, slightly more echogenic focally or diffusely compared to normal with hyperemia on color flow Doppler US. The surrounding subcutaneous tissue was thick and echogenic. Two abscesses presented as avascular areas without color flow on Doppler US, subtly increased through-transmission and surrounding hyperemia. One abscess was of increased echogenicity while the other was anechoic.

CONCLUSION

Neonatal mastitis and breast abscess are unusual diseases that should be appropriately treated with antibiotics and drainage to avoid generalized sepsis, breast hypoplasia, and scarring. US is useful in distinguishing mastitis from breast abscess and guiding treatment options.

Mastitis in children from birth to 17 years

Twenty-two cases of mastitis were evaluated between 1995 and 2003. Nine of the children were younger than 2 months of age, and 12 were older than 8 years of age. Girls accounted for 82% of the cases. Seven of the infections were true abscesses. Pathogens included Staphylococcus aureus in 5, Gram-negative bacilli in 3, group A Streptococcus in 1 and enterococcus in 1. These data suggest that mastitis in children occurs in 2 distinct age groups, neonates and pubescent/postpubescent; however, the clinical disease is similar in both populations.

Mastitis in early infancy

AIM

To evaluate the clinical features and microbiological findings in young infants with mastitis.

METHODS

Retrospective review of medical records of 18 infants with breast inflammation during the first 3 mo of life seen in the paediatric emergency department between 1992 and 2002.

RESULTS

All were full-term infants with female-male ratio of 3.5:1. The age ranged from 12 to 45 d, with a peak in the 4th and 5th weeks of life. Only five patients had systemic manifestations, and five were pretreated with oral antibiotics (amoxicillin-clavulanic acid). The latter as well as seven additional cases required incision and drainage due to abscess formation. Bacterial cultures grew Staphylococcus aureus in 10 cases including all pretreated infants. In four of these cases, Gram stain showed the pathogen. After antimicrobial treatment, no recurrence was observed in any of the patients.

CONCLUSIONS

These findings suggest that mastitis in early infancy should be treated with parenteral antibiotics guided by Gram stain when available and informative. Otherwise, beta-lactamase-resistant antibiotics are a reasonable empirical initial treatment pending culture results. Optimizing the management of infants with mastitis is important especially since abscess formation requiring incision may be detrimental for later breast development.

Cutaneous and subcutaneous infections in newborns due to anaerobic bacteria

This review describes the microbiology and management of the major cutaneous and subcutaneous infections in newborns where anaerobic bacteria predominate: omphalitis, necrotizing fasciitis, breast abscess, and scalp infection following intrauterine fetal monitoring. The predominant bacteria known to cause these infections are group B streptococcus, group D enterococcus, group A streptococcus, Staphylococcus aureus, Enterobacteriaceae, and anaerobic bacteria. All of these agents can colonize or infect the mother and subsequently colonize or infect the fetus or newborn either intrauterinely or during the passage through the birth canal. Infections due to anaerobes are often polymicrobial, and include also aerobic and facultative bacteria. The anaerobes recovered from these infections are Bacteroided fragilis group, Fusobacterium spp., Peptostreptococcus spp. and Clostridium spp. Early recognition and effective medical and surgical therapy are essential to recovery. Managements of these infections include surgical debridement and drainage when appropriate as well as topical and systemic use of antimicrobial agents effective against both aerobic and anaerobic bacteria.

Subclinical mastitis presenting as acute, unexplained, excessive crying in an afebrile 31-day-old female

We present a case of a 31-day-old female who presented with an acute, unexplained, episode of excessive crying. The patient had no history of fever and no fever on presentation. There was no evidence of skin erythema or swelling on presentation. Chest radiograph and computed tomography of the head were normal. Urinalysis and cerebral spinal fluid analysis were normal. The white blood cell count was within normal limits (17,400 cells/mm3). It was not until 6 hours after the onset of inconsolable crying (2.5 hours after presentation to the emergency department) that the patient's temperature rose to 38.5 degrees C (101.3 degrees F). Clinical signs of mastitis did not become appreciable until the 2nd hospital day. We review the literature on infantile mastitis and acute, unexplained, excessive crying. The importance of a thorough, conservative approach to the infant with acute, unexplained, excessive crying is discussed.

Dermatologic diseases of the breast and nipple

Breast and nipple skin is commonly affected by various inflammatory and neoplastic processes. Despite this fact, many physicians are unaware of the spectrum of diseases that can involve this area. Because breast and nipple skin represents a cosmetically, sexually, and functionally important entity to most patients, awareness of these disease entities is invaluable. This article reviews the normal anatomy of the breast, cutaneous manifestations of neoplastic processes that can present in these areas, and common inflammatory diseases of the breast and nipple skin.