Ultrasound-guided drainage of breast abscesses: results in 151 patients

'I don't want to be a guinea pig' - Swedish women's experiences of breast abscess treatment

BACKGROUND

It is well known that breastfeeding plays an important role in the health of women and children. However, women are not always given optimal support and most do not reach their breastfeeding goals. About one in five, breastfeeding women report mastitis and a small proportion of these develop a breast abscess. Our aim was to describe the experiences of a group of Swedish breastfeeding women who developed a breast abscess.

METHODS

A qualitative cross-sectional study with 18 study participants was undertaken in Sweden in 2017-2018. Potential participants were identified through electronic medical records at a university hospital and invited to participate in audio-recorded telephone interviews. Women were between 2 and 24 months postpartum at the time of the interview, on average 8 months. We conducted a thematic analysis in six steps according to Braun and Clark.

RESULTS

Our analysis identified two themes: 1) Seeking care and receiving treatment was long and unpleasant, and 2) Importance of adequate professional care. Women who experienced a breast abscess were uncertain about where to ask for professional help. They often had a long wait for the right time to undergo the unpleasant and painful procedure of draining their breast abscess. The women felt it was important to receive professional care with respectful communication, continuity of care, and to receive adequate information, but they did not always receive this level of care.

CONCLUSIONS

Women with puerperal breast abscesses often fall between medical specialty areas. No longer under the care of obstetricians and maternity services, their problem is too complicated for general practitioners or emergency departments, but not regarded as serious by breast surgeons. Healthcare professionals urgently need adequate training in order to deal with breastfeeding problems and be able to offer women-centred care.

Breast infections: A review of current literature

Breast infections are common, affect women of all ages, and are associated with significant morbidity. Despite overall prevalence, treatment varies significantly based on provider or institution and no central treatment guidelines exist to direct the management of breast infections. This article provides a summary of the current trends in management of breast infections. The etiology, epidemiology, risk factors, presentation, diagnosis, and treatment of mastitis and breast abscesses (and their relative subdivisions) are explored based on the current literature. Trends in microbiology are reviewed and an approach to antibiotic coverage is proposed. Overall, there is a lack of randomized-controlled trials focused on the treatment of breast infections. This has resulted in an absence of clinical practice guidelines for the management of breast abscesses and variable practice patterns. The development of best-care protocols or pathways could provide more uniformity in care of breast infections.

A Randomized Controlled Trial Comparing Ultrasonography-Guided Needle Aspiration and Surgical Drainage for the Management of Breast Abscess

Background A breast abscess is a localized collection of inflammatory exudate in breast tissue. It is more common in lactating women. Treatment of the breast abscess is usually by incision and drainage, which is accompanied by extensive trauma, lengthy surgical incisions, psychological distress, surgical scar, and discomfort during dressing changes. Recent research has shown that ultrasonography-guided needle aspiration is an alternative to incision and drainage for breast abscess treatment, has superior cosmetic outcomes, and has fewer costs. However, there are no clear guidelines for the same. The primary objective of this study was to assess and contrast the outcomes and efficacy of two approaches in the treatment of breast abscesses: ultrasonography-guided needle aspiration and conventional incision and drainage. Methods This was a single-center, prospective, randomized, controlled, non-inferiority trial. Patients with breast abscesses were randomized either to receive needle aspiration or incision drainage. Patients with lactational breast abscesses were encouraged to breastfeed from either breast. The antibiotic was given for 10 days to all the patients. The study's main focus was on the primary outcome, which was the failure rate. Additionally, several secondary outcomes were examined, including postoperative pain, time required for healing, presence of residual abscess or recurrence, formation of fistulas, and the assessment of scar appearance. Results A total of 44 patients were randomized to 23 and 21 in each arm. There was no statistical difference in treatment failure (p-value=0.862), fistula formation (p-value=1.00), and recurrence (p-value=1.00). There was a significant statistical difference in healing period (p-value <0.001), scar formation (p-value <0.0001), continuation of breastfeeding (p-value=0.005), and clinical resolution (p-value=0.002). There was a significant reduction in post-intervention pain in the needle aspiration group than in the other group (p-value <0.001). Conclusion This study showed a significant difference in postoperative pain, healing time, the continuation of breastfeeding, and scar formation in the needle aspiration group, favouring minimally invasive treatment for breast abscess. However, due to the small sample size, we could not conclude that ultrasonography-guided needle aspiration of the breast abscess is non-inferior to the conventional incision and drainage.

Application of arthroscopic system in the treatment of lactational breast abscess

Purpose

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

Methods

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

Results

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

Conclusion

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

Management of Breast Abscess during Breastfeeding

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

Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Treatments for Periductal Mastitis: Systematic Review and Meta-Analysis

Introduction

Periductal mastitis (PDM) is a complex benign breast disease with a prolonged course and a high risk of recurrence after treatment. There are many available treatments for PDM, but none is widely accepted. This study aims to evaluate the various treatment failure rates (TFR) of different invasive treatment measures by looking at recurrence and persistence after treatment. In this way, it sets out to inform better clinical decisions in the treatment of PDM.

Methods

We searched PubMed, Embase, and Cochrane Library databases for eligible studies about different treatment regimens provided to PDM patients that had been published before October 1, 2019. We included original studies written in English that reported the recurrence and/or persistence rates of each therapy. Outcomes were presented as pooled TFR and 95% CI for the TFR.

Results

We included 27 eligible studies involving 1,066 patients in this study. We summarized 4 groups and 10 subgroups of PDM treatments, according to the published studies. Patients treated minimally invasively (group 1) were subdivided into 3 subgroups and pooled TFR were calculated as follows: incision and drainage (n = 73; TFR = 75.6%; 95% CI 27.3-100%), incision alone (n = 74; TFR = 20.1%; 95% CI 0-59.9%), and breast duct irrigation (n = 123; TFR = 19.4%; 95% CI 0-65.0%). Patients treated with a minor excision (excision of the infected tissue and related duct; group 2) were divided into 4 subgroups and pooled TFR were calculated as follows: wound packing alone (n = 127; TFR = 2.1%; 95% CI 0-5.2%), primary closure alone (n = 66; TFR = 37.1%; 95% CI 9.5-64.8%), primary closure under antibiotic treatment cover (n = 55; TFR = 4.8%; 95% CI 0-11.4%), and additional nipple part removal (n = 232; TFR = 9.6%; 95% CI 5.8-13.4%). Patients treated with a major excision (excision of the infected tissue and the major duct; group 3) included the following 2 subgroups: patients treated with a circumareolar incision (n = 142; TFR = 7.5%; 95% CI 0.4-14.7%) and patients treated with a radial incision of the breast (n = 78; TFR = 0.6%; 95% CI 0-3.6%). Group 4 contained patients receiving different major plastic surgeries. The pooled TFR of this group (n = 86) was 3.4% (95% CI 0-7.5%).

Conclusion

Breast duct irrigation, which is the most minimally invasive of all of the treatment options, seemed to yield good outcomes and may be the first-line treatment for PDM patients. Minor excision methods, except for primary closure alone, might be enough for most PDM patients. Major excision, especially with radial incision, was a highly effective salvage therapy. The major plastic surgery technique was also acceptable as an alternative treatment for patients with large lesions and concerns about breast appearance. Incision and drainage and minor excision with primary closure alone should be avoided for PDM patients. Further research is still needed to better understand the etiology and pathogenesis of PDM and explore more effective treatments for this disease.

Treatment of lactational breast abscesses with cavity diameter larger than 5 cm via combined ultrasonography-guided percutaneous catheter placement and hydrostatic pressure irrigation

This study reports on our experience of treating lactational breast abscesses larger than 5 cm via ultrasonography (US)-guided percutaneous catheter placement and hydrostatic pressure irrigation. Twelve cases of puerperal single breast abscesses larger than 5 cm were collected. These patients were treated with US-guided percutaneous catheter placement and hydrostatic pressure irrigation combined with oral antibiotics. All 12 patients using US-guided treatment were completely successful without conversion to open surgical drainage. The range of recovery time was 5-16 days, and no major complications occurred. The patients were satisfied with the appearance of the scar, and there were no reports of recurrence during the follow-up period.Overall, US-guided percutaneous catheter placement and hydrostatic pressure irrigation are successful strategies for the treatment of lactational breast abscesses larger than 5 cm. These methods not only reduce the treatment time and improve the patients' clinical course but also provide cosmetic effects.IMPACT STATEMENTWhat is already known on this subject? The current consensus on breast abscess treatment is that lesions <3 cm can be effectively treated by aspiration alone, lesions >3 cm require catheter drainage, lesions <5 cm have proven to be safe and effectively treated by US-guided ultrasound therapy, and lesions >5 cm, whether multi-loculated or longstanding, require surgical incision and drainage.What do the results of this study add? We tried to use this method to increase the cure rate of US-guided minimally invasive treatment for large abscesses. The results showed that all patients were cured successfully, requiring no further surgical intervention. Moreover, no complications occurred, and no patients developed sequelae. During the three-month follow-up period, there was no evidence of recurrence in any case.What are the implications of these findings for clinical practice and/or further research? Questions remain regarding the treatment's generalisability, potentially lengthy hospitalisation, and technical limitations of the existing instrumentation. Long-term follow up and larger sample size Randomised clinical trials studies are still needed to rigorously and scientifically ensure the method's benefits over conventional open surgery in the future.

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

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

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

BACKGROUND

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

OBJECTIVE

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

DISCUSSION

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

CONCLUSIONS

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

Benign Breast Disease in Women

BACKGROUND

Most clinical breast changes in women are benign; in only 3% to 6% of cases are they due to breast cancer. How- ever, there is a lack of up-to-date, evidence-based treatment recommendations for the various benign differential diagnoses.

METHODS

Selective literature search of PubMed from 1985 to May 2019, including current national (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften [Association of Scientific Medical Societies in Germany]) and inter- national guidelines.

RESULTS

Mastalgia and fibrocystic changes are common (around 50% of all women over the age of 30). Fibroadenomas occur in 25% of women; they are the most common benign tumors of the breast and do not require treatment. With most benign breast changes the risk of dedifferentiation is very low. However, it is important in the differential diagnosis to distinguish between such benign changes and breast cancer or changes that carry a risk of malignancy. Complex cysts, for example, carry a risk of malig- nancy of 23% to 31%, papillary lesions 16% , and radial scars 7%. Where there is doubt, histological confirmation should be sought by means of percutaneous biopsy.

CONCLUSION

Benign breast changes can be definitively distinguished from malignant lesions through the selective use of avail- able diagnostic investigations and interdisciplinary collaboration. When lesions of uncertain malignant potential are found (B3 in the biopsy classification), complete excision is indicated. Prospective studies on the early diagnosis of breast cancer in lesions carrying a risk of malignancy are desirable.

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.

Surgical drainage of lactational breast abscess with ultrasound-guided Encor vacuum-assisted breast biopsy system

Lactational breast abscess is a serious complication of mastitis and commonly diagnosed in breast-feeding women. The traditional drainage of breast abscess was often performed with incisive technique which may result in prolonged healing time, regular dressings, dressing pain, interfering with breastfeeding and unsatisfactory cosmetic outcome. As minimal invasive alternatives to incisive drainage, needle aspiration or percutaneous catheter placement cannot completely replace incisive drainage for the inability to treat large, multiloculated or chronic abscess. Vacuum-assisted breast biopsy system (VABB) has been successfully applied in the treatment of benign breast diseases with satisfactory cosmetic outcomes. Among VABB devices, EnCor system has some distinctive features that make it an appropriate candidate for the treatment of lactational breast abscesses. In this study, for the first time, we investigated the feasibility, efficacy, and cosmetic results of surgical drainage of lactational breast abscess with US-guided Encor VABB system. Our data suggests this procedure could serve as a promising alternative for women with lactational breast abscess who require incisive intervention with high cure rate, relatively short healing time, low recurrence rate, few complications, satisfactory cosmetics outcome and without interfering with breastfeeding.

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

BACKGROUND

Surgical incision with drainage remains the first-line therapy recommendation for breast abscesses greater than 5 cm.

PURPOSE

To determine recovery with ultrasound guided (US-guided) procedures for treatment of lactational breast abscesses without surgical incision for drainage.

MATERIAL AND METHODS

Institutional review board approval and written informed patient consent were obtained for this retrospective study. From May 1, 2009, to June 1, 2018, 92 consecutive women (mean age 30 years, range 18-45) with 105 abscesses were treated with oral antibiotics and US-guided percutaneous drainage under local anesthesia. A total number of 202 US-guided procedures were performed. Three techniques were used: needle aspiration (diameter 18 to 14G), pigtail catheter insertion (diameter 5 to 7F), and/or vacuum-assisted biopsy/aspiration (diameter 10G). When using needle aspiration or pigtail catheter, a saline irrigation of the cavity was performed according to pus viscosity.

RESULTS

The median diameter of abscesses was 4.5 cm (range 1-15), 82/105 (78%) were larger than 3 cm and 40/105 (38%) larger than 5 cm. US-guided management was successful for 101/105 (96%; 95% CI, (91-99%)) abscesses regardless the size. After the first round of procedures, 49/105 (47%) abscesses were recovered, 56/105 (53%) needed more than one drainage with a median number drainages of 2.6 (2-6). In 4/105 cases (4%), women underwent additional surgery under general anesthesia. By excluding abscesses which occurred in the weaning phase (n = 17), breastfeeding carried on for 68/75 (91%) women.

CONCLUSION

Unlike previous studies, US percutaneous guided management of lactational abscesses is effective even for abscesses greater than 5 cm and allows continued breastfeeding.

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.

Impact on Clinical Management of After-Hours Emergent or Urgent Breast Ultrasonography in Patients with Clinically Suspected Breast Abscesses

Newly diagnosed breast abscesses are generally treated as a medical emergency that may necessitate immediate interventional treatment. At our institution, there is no in-house after-hours coverage for breast ultrasonography. We could find no peer-reviewed studies on the cost-effectiveness or clinical management impact of on-call ultrasound technologist coverage for imaging of breast abscesses. The purposes of this study were to determine the incidence of breast abscess in patients with clinical findings highly suggestive of abscess, identify clinical factors associated with breast abscess in such patients, and determine the impact of after-hours emergent or urgent breast ultrasonography on the clinical management of breast abscesses in both outpatients and inpatients. We retrospectively reviewed 100 after-hours breast ultrasound studies performed at our tertiary care center from 2011 to 2015 for evaluation of a suspected breast abscess. Only 26% of our patients with clinically suspected abscess ultimately had a confirmed abscess. Factors associated with breast abscess were a palpable abnormality and a history of breast surgery within the eight weeks before presentation. After-hours diagnosis of an abscess was associated with after-hours clinical intervention. Of the 74 patients in whom after-hours ultrasound imaging showed no evidence of abscess, only three patients underwent after-hours drainage. Our findings support overnight and weekend breast ultrasound coverage in large tertiary care centers.

Trends in non-lactation breast abscesses in a tertiary hospital setting

BACKGROUND

The aim of this paper was to retrospectively review non-lactation breast abscesses treated in Princess Alexandra Hospital over a 10-year period and to illustrate the trends in size, risk factors, microbiological profile and management.

METHODS

A computerized search of the medical records was undertaken to identify all adult patients with a diagnosis of breast abscesses during June 2005-June 2015. Patients concurrently breastfeeding were excluded. A retrospectively review of the clinical records was performed.

RESULTS

Eighty-five abscesses were identified in 77 patients. The median patient age was 45 years and 93.7% were females. Smoking and diabetes mellitus were associated with a longer inpatient hospital stay. There was a significant difference in microbiology of abscesses in relation to size. Smaller abscesses (≤3.0 cm) predominantly had mixed anaerobes (54%), whereas larger abscesses had a dominance of Staphylococcus aureus (29%) and other aerobic microbes (33%) (P < 0.05). Seven percent of all abscesses had methicillin-resistant S. aureus. Flucloxacillin was prescribed solely in majority of the cases (45%) with addition of suitable mixed anaerobic cover in 12% cases. Of the 85 abscesses, 58.8% were managed non-operatively with antibiotics ± percutaneous drainage. Percutaneous aspiration had a shorter inpatient stay compared with patients who underwent operative management.

CONCLUSION

This represents the first Australian study solely analysing non-lactation breast abscess. Size was correlated significantly to characteristic bacteriology and empiric therapy should include both aerobic and anaerobic cover. The majority of non-lactation breast abscesses can be managed non-operatively with a combination of antibiotics and percutaneous aspiration.

Ultrasound-Guided Percutaneous Catheter Drainage of Large Breast Abscesses in Lactating Women: How to Preserve Breastfeeding Safely

INTRODUCTION

Management of breast abscess in lactating women remains controversial. During pregnancy, women may develop different kinds of benign breast lesions that could require a surgical incision performed under general anesthesia with consequent breastfeeding interruption. The purpose of this study was to prospectively evaluate the management of large breast abscesses with ultrasound-assisted drainage aiming at breastfeeding preservation.

MATERIALS AND METHODS

34 lactating women with a diagnosis of unilateral breast abscess have been treated with an ultrasound (US)-assisted drainage of the abscess. A pigtail catheter was inserted into the fluid collection using the Seldinger technique under US guide and connected to a three stop way to allow drainage and irrigation of the cavity until its resolution.

RESULTS

All procedures have been found safe and well tolerated. No recurrence was observed and breastfeeding was never interrupted.

CONCLUSIONS

The described technique allows to avoid surgery and to preserve breastfeeding in well-selected patients with a safe, well-tolerated and cost-effective procedure.

Surgical wound assessment by sonography in the prediction of surgical wound infections

BACKGROUND

Surgical site infections (SSIs) are important sources of morbidity, prolonged hospital stays, and readmissions, so they have become a major economic burden. We hypothesized that surgical wound assessment by sonography (SWATS) used at the bedside would detect wound fluid collections and that the presence of such collections would predict SSI better than standard clinical examination. If so, SWATS might be used to indicate early intervention that could prevent SSI morbidity.

METHODS

A prospective, single-institution observational study was conducted on adult inpatients following open abdominal surgery for trauma, gastrointestinal pathology, or biliary pathology at high risk (>5%) for SSI using traditional wound classifications. After informed consent was obtained, SWATS was performed using a smartphone-based ultrasound system on postoperative Day 2 to 4 and again before discharge or at postoperative Day 30, whichever came first. Primary treating physicians delivered standard wound care and were blinded to SWATS. SSI was diagnosed if treatment was implemented for suspected or documented wound infection by the treating physician. Results were analyzed by χ test and two-sample pooled variance t test where appropriate, with significance set at p < 0.05.

RESULTS

Forty-nine patients were studied. Nineteen patients had peri-incisional fluid collections found by SWATS. Eight of these patients went on to develop an SSI. SSI was significantly associated with the presence of fluid collections on SWATS (p = 0.009). SWATS had a sensitivity of 72.7% (0.43-0.92), a specificity of 71.1% (0.62-0.77), a positive predictive value of 42.1% (0.25-0.53), and a negative predictive value of 90.0% (0.79-0.97).

CONCLUSION

SWATS has a high negative predictive value that may allow it be an effective screening tool for developing SSI in high-risk surgical wounds. SWATS has the potential to be a useful and cost-effective adjunct to the clinician by objectively suggesting need for early therapy. Further study with larger sample sizes and randomized, SWATS-based interventions are required to validate this small study and determine its place in clinical care.

LEVEL OF EVIDENCE

Diagnostic study, level IV.

Evaluation of ultrasonography as a diagnostic tool in the management of head and neck facial space infections: A clinical study

Introduction:

Superficial facial space infections represent a significant amount of the dental problems that present to hospital. Determining whether an odontogenic swelling is a cellulitis or abscess is difficult, but important as both may require different treatments. The use of an ultrasound may aid in differentiating cellulitis and abscess. This study was done to compare the accuracy of clinical examination alone versus ultrasonography (USG) in the diagnosis of cellulitis and abscess in symptomatic patients with a diagnosis of superficial facial space infection.

Materials and Methods:

Twenty patients (1870 years) diagnosed as superficial facial space infections by clinical and radiographic examinations were included in the study and patients with significant medical conditions were excluded. The provisional clinical diagnosis was made after a thorough history was taken and clinical examination was performed to determine if the swelling was a cellulitis or abscess. Swelling was then evaluated using the ultrasonic transducer which was placed over the swelling to aid the diagnosis which was again recorded. An incision and drainage procedure was performed after the administration of local anesthesia. The success of the ultrasound intervention versus clinical examination was based on whether frank exudation was detected during incision and drainage of such swellings.

Results:

The statistical analysis found that USG is a valuable diagnostic aid for detection of abscess or cellulitis in head and neck facial space infections.

Interpretation and Conclusion:

The findings of this prospective analysis indicate that there was statistical difference between clinical examination alone and USG in making the correct diagnosis. The sensitivity, specificity, positive predictive, negative predictive, and accuracy were not similar for all methods tested. From the results of this study, ultrasound is recommended as an adjunct to clinical examination in differentiating between cellulitis and abscess.

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.

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

PURPOSE

Our purpose was to review needle aspiration of breast abscesses and identify factors associated with treatment by aspiration alone versus aspiration with surgical incision and drainage (I/D).

METHODS

This Institutional Review Board-approved, retrospective review of the breast ultrasound database from 2008 to 2010 identified 40 patients (41 abscesses) who underwent aspiration, with or without I/D. Demographics, imaging, number of aspirations, and microbiology were reviewed.

RESULTS

Twenty-two abscesses underwent aspiration only, 16 > 3 cm, 6 ≤ 3 cm (mean 4.3 cm, range 0.9-10 cm). Known risk factors included lactational (11), 3 weeks post partum (1), pregnancy (1), recent biopsy/lumpectomy (5). Nineteen abscesses underwent aspiration and I/D, 15 > 3 cm, 4 ≤ 3 cm (mean 4.1 cm, range 2.2-7.5 cm). Known risk factors included lactational (4), recurrent subareolar abscess (4), diabetes (3), hydradenitis suppuritiva (1), nipple piercing (2), smoking (1), pregnancy (1), HIV (1), and lumpectomy (1). Identified reasons for I/D included lack of improvement/recurrence (12), fistula (3), and one electively after clinical improvement of a recurrent subareolar abscess.

CONCLUSIONS

Abscesses associated with pregnancy and lactation or breast biopsy are effectively managed with aspiration, even when large. Recurrence, chronicity, or fistula may require surgical intervention.

Ultrasound-guided diagnosis and aspiration of subdeltoid abscess from heroin injection

A 49-year-old man presented to the emergency department (ED) with shoulder pain after intramuscular injection of heroin into his right deltoid muscle. Point-of-care (POC) ultrasound identified a subdeltoid abscess, and ultrasound-guided aspiration of the fluid collection was performed. The patient was admitted and improved on antibiotics and made a complete recovery. POC ultrasound and ultrasound-guided aspiration can assist in the diagnosis and treatment of deep musculoskeletal abscesses.

ABM clinical protocol #4: Mastitis, revised March 2014

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Uncommon benign breast abnormalities in adolescents

The authors discuss benign breast abnormalities in the adolescent breast other than fibroadenoma. Although fibroadenoma is the most common benign abnormality in the adolescent breast, other diagnoses are possible. The majority of adolescents who present with a palpable concern or lump have no discrete abnormality on ultrasound and are diagnosed with clinical fibrocystic change and followed up to ensure clinical stability. Intraductal papilloma and duct ectasia are two benign abnormalities associated with bloody nipple discharge, occurring more rarely in adolescents compared with adult women. Breast infections can occur in adolescents, including both mastitis and/or abscess, and are treated similarly to adults, with drainage and antibiotic coverage for Staphylococcus. When infections are due to nipple piercing, other organisms should be suspected. All surgical procedures in the developing breast should be performed cautiously, as trauma to the undeveloped breast can result in failure of breast development or asymmetry, and surgical disruption of subareolar ducts can impair or preclude future lactation.

Breast abscess: evidence based management recommendations

Literature review was carried out and studies reporting on treatment of breast abscesses were critically appraised for quality and their level of evidence using the Strength of Recommendation Taxonomy guidelines, and key recommendations were summarized. Needle aspiration either with or without ultrasound guidance should be employed as first line treatment of breast abscesses. This approach has the potential benefits of: superior cosmesis, shorter healing time, and avoidance of general anaesthesia. Multiple aspiration sessions may be required for cure. Ultrasound-guided percutaneous catheter placement may be considered as an alternative approach for treatment of larger abscesses (>3 cm). Surgical incision and drainage should be considered for first line therapy in large (>5 cm), multiloculated, or long standing abscesses, or if percutaneous drainage is unsuccessful. All patients should be treated concurrently with antibiotics. Patients with recurrent subareolar abscesses and fistulas should be referred for consideration of surgical treatment.

Role of ultrasonography in differentiating facial swellings of odontogenic origin

INTRODUCTION

Differentiating an acute, odontogenic facial swelling clinically as cellulitis or an abscess has not been thoroughly investigated in endodontics. It has been suggested in the medical and dental literature that the use of ultrasound may aid in differentiating cellulitis from an abscess. Therefore, if ultrasound were more accurate than a blind incision for drainage procedure in locating purulence, perhaps the outcome of the incision for drainage procedure would be beneficial in the resolution of odontogenic infections. The purpose of this prospective study was to compare clinical examination plus ultrasonography versus clinical examination alone in differentiating cellulitis from abscesses in patients with facial swelling of odontogenic origin.

METHODS

Eighty-two emergency patients participated in this study. Each patient was examined and diagnosed by clinical examination and clinical examination plus ultrasonography. An incision for drainage procedure was performed, and a definitive diagnosis was recorded as cellulitis (no purulence) or an abscess (presence of purulence).

RESULTS

With the incision for drainage procedure, cellulitis occurred 37% of the time and abscesses 63%. With clinical examination alone, a correct diagnosis was made 68% of the time. With clinical examination plus ultrasonography, a correct diagnosis was made 70% of the time. There was no statistically significant difference between the 2 examination methods.

CONCLUSIONS

The addition of ultrasonography to a clinical examination did not significantly increase the number of correct diagnoses.

Breast disease in the pregnant and lactating patient: radiological-pathological correlation

OBJECTIVE

Substantial physiological changes occur during pregnancy and lactation, making breast evaluation challenging in these patients. This article reviews the imaging challenges of the breast during pregnancy and lactation. The normal imaging appearance, imaging protocols and the imaging features of each commonly encountered benign and malignant entity with pathological correlation and supporting examples is described. An awareness of the imaging features of the breast during these physiological states and of various benign and malignant diseases that occur permits optimal management.

CONCLUSIONS

Evaluation of the pregnant and lactating patients who present with a breast problem is challenging. Although ultrasound may characterise the finding in many cases, mammography and even MRI may have a role in the management of these patients.

TEACHING POINTS

• To review physiological changes of the breast during pregnancy and lactation • To review imaging protocols of the breast during pregnancy and lactation • Discuss imaging findings with pathological correlation of benign and malignant diseases in pregnancy and lactation • Discuss pathological correlation of imaging findings in pregnancy and lactation.

Health and economic burden of post-partum Staphylococcus aureus breast abscess

Objectives

To determine the health and economic burdens of post-partum Staphylococcus aureus breast abscess.

Study design

We conducted a matched cohort study (N = 216) in a population of pregnant women (N = 32,770) who delivered at our center during the study period from 10/1/03–9/30/10. Data were extracted from hospital databases, or via chart review if unavailable electronically. We compared cases of S. aureus breast abscess to controls matched by delivery date to compare health services utilization and mean attributable medical costs in 2012 United States dollars using Medicare and hospital-based estimates. We also evaluated whether resource utilization and health care costs differed between cases with methicillin-resistant and -susceptible S. aureus isolates.

Results

Fifty-four cases of culture-confirmed post-partum S. aureus breast abscess were identified. Breastfeeding cessation (41%), milk fistula (11.1%) and hospital readmission (50%) occurred frequently among case patients. Breast abscess case patients had high rates of health services utilization compared to controls, including high rates of imaging and drainage procedures. The mean attributable cost of post-partum S. aureus breast abscess ranged from $2,340–$4,012, depending on the methods and data sources used. Mean attributable costs were not significantly higher among methicillin-resistant vs. –susceptible S. aureus cases.

Conclusions

Post-partum S. aureus breast abscess is associated with worse health and economic outcomes for women and their infants, including high rates of breastfeeding cessation. Future study is needed to determine the optimal treatment and prevention of these infections.

Comparison of Incision and Drainage against Needle Aspiration for the Treatment of Breast Abscess

We aim to compare the incision and drainage against ultrasound-guided aspiration for the treatment of breast abscesses. Sixty-four patients were randomly allocated to Group A (incision and drainage) and Group B (needle aspiration). Incision and drainage was done under general, whereas aspiration was done under local anesthesia with antibiotic coverage after the pus sample was taken for cultures. Time taken to resolve symptoms including point tenderness, erythema and hyperthermia, recurrence of breast abscess, and healing time was recorded. Patients were followed until 8 weeks. Culture and sensitivity of the pus were done. Data were analyzed in SPSS 16.0. The mean difference of healing time was significant ( P = 0.001). A total of 93.3 per cent were healed in Group B and 76.6 per cent in Group A ( P = 0.033). Twenty-two samples (34.37%) had no bacterial yield and the remaining 42 samples (65.6%) yielded 11 anaerobic cultures (17.18%) and 31 aerobic cultures (48.4%). Ultrasound-guided aspiration of breast abscesses with the judicious use of antibiotics is a better treatment modality than incision and drainage.

Converting emergency pilonidal abscess into an elective procedure

BACKGROUND

Improvements in outcome after surgery for elective pilonidal sinus disease have yet to be matched for those presenting with acute disease. Traditional approaches to the management of acute pilonidal abscess have been associated with slow healing and significant loss of working time.

OBJECTIVE

The aim of this study was to report our approach in which a temporizing intervention allows subsequent definitive treatment with low morbidity.

DESIGN

This article presents a prospective cohort study.

SETTING

This study was performed in acute admissions to the Surgical Unit in York Teaching Hospital.

PATIENTS

Patients presenting with acute pilonidal abscess, not septic, immune-compromised, or diabetic, and without skin necrosis, underwent aspiration on the surgical ward.

INTERVENTION

Aspiration of pilonidal abscess under local anesthetic was performed with the use of a wide-bore needle. The abscess cavity was drained to dryness, samples were sent to the laboratory for microbiology, and empirical oral antibiotics were commenced, covering anaerobes and aerobes. Review was arranged for within 7 days to plan elective excision and primary closure of the underlying pilonidal sinus.

MAIN OUTCOME MEASURES

The primary outcomes measured were the number of days required to return to normal activities, response to treatment, and any residual inflammation.

RESULTS

Fifty-six patients were referred with acute pilonidal abscess. Forty patients met the criteria for aspiration and empirical antibiotic treatment. All were allowed to go home the same day and were reviewed within a median of 5 days. Thirty-eight (38/40) patients demonstrated complete resolution of acute inflammation and were back to normal activities the following day. Fifteen patients subsequently underwent day-case excision and primary closure at a median of 9 weeks. Another 13 are awaiting surgery, and 10 patients have declined further treatment. Two (2/40) patients did not respond, one of whom did not receive the appropriate antibiotics. Both were managed with incision and drainage.

CONCLUSIONS

Aspiration and antibiotic management of pilonidal abscess is effective in 95% of acute cases in preventing the need for emergent laying open and allows for subsequent elective surgery.

Breast Abscesses: Diagnosis, Treatment and Outcome

BACKGROUND: The aim of our study was to analyze diagnostic results, different treatment modalities, and the outcome of patients with breast abscesses treated at our institution in a multi-modality breast team, to determine whether minimally invasive treatments are successful. METHODS: 110 patients with mastitis and suspected breast abscesses at our institution between January 2000 and end of September 2007 were retrospectively analyzed. Abscesses were diagnosed using ultrasonography (US), and the material obtained using US-guided fine needle aspiration (FNA) was further examined. RESULTS: 29% of the patients were treated conservatively with antibiotics only, 51% were treated with US-guided FNA or drainage placement. 11% of the patients underwent additional surgery after minimally invasive treatment (i.e. conversion rate). 9% of the patients underwent primary surgery. Early complications occurred in 7% of patients treated minimally invasive but not in patients treated with surgery alone. Late complications occurred in 5% of patients who underwent minimally invasive treatments and in 30% of patients who underwent surgery. CONCLUSIONS: US-guided FNA as a minimally invasive therapy in combination with antibiotics was found to successfully treat most breast abscesses and, in cases where a larger volume of pus was involved, the placement of an additional drainage catheter was effective.

Ultrasound in dermatology: principles and applications

Ultrasonic imaging has been used in the field of dermatology for nearly 30 years. In this review, we seek to explain the basic principles of ultrasound as they relate to the skin. Based on differences in keratin, collagen, and water content, ultrasonic waves are reflected back to a transducer and translated into a gray-scale image for interpretation. The technicalities of the process and its variations (power, continuous wave Doppler ultrasound, ultrasound elastography) are briefly reviewed, and we further highlight many of the applications for ultrasound in the treatment and diagnosis of dermatologic conditions, including melanoma and nonmelanoma skin cancer, benign tumors, inflammatory diseases, and lipoablation. Each of these entities is uniquely characterized using ultrasonic techniques. Based on published sources, we contend that although ultrasound is still being fine-tuned for application in dermatology and largely remains in experimental phases, it has potential for use in many arenas of our specialty.

Detection of subcutaneous and intramuscular air with sonography: a sensitive and specific modality

OBJECTIVES

Soft tissue air may raise suspicion for several life-threatening illnesses. Physical examination has limited sensitivity in detecting air, and computed tomography and magnetic resonance imaging are time-consuming and expensive. Sonography can show soft tissue air, but the sensitivity and specificity in this setting are currently unknown. Therefore, the purpose of this study was to assess the performance characteristics of sonography in depicting the presence, amount, and affected tissue plane in a cadaver model of soft tissue air.

METHODS

We conducted a single-blinded observational cadaver study. Cutaneous sites were selected and marked (≈4 or 5 sites on each of 6 cadavers). An examiner injected air at some sites, recording both the depth (plane) and volume. A second examiner, who was blinded to the injection procedure, examined each site with sonography and recorded the presence or absence of air and the plane (subcutaneous or intramuscular). The results were compared, and statistical analysis was performed.

RESULTS

Twenty-eight sites on 6 cadavers were used. Sites were not used if they were damaged or were within 10 cm of previous dissection. Air was injected in 20 of 28 sites; the remaining 8 were sham injections. Sonography showed air in all of the 20 sites with air injected. No air was detected in 7 of the 8 remaining sham sites, yielding 1 false-positive case. The plane was accurately assessed in all cases. Sensitivity for detection was 100%, and specificity was 87.5%.

CONCLUSIONS

Sonography accurately showed the presence, amount, and anatomic plane of soft tissue air in cadavers with sensitivity of 100%. It warrants investigation as a screening test in patients at high risk for subcutaneous air from conditions such as necrotizing fasciitis and gas gangrene.

A study of the microbiology of breast abscess in a teaching hospital in Kuwait

OBJECTIVES

To determine the microbiological profile of breast abscess and assess the antibiotic susceptibility of the causative agents.

MATERIALS AND METHODS

Data obtained from cases of breast abscess over a period of 3.5 years, June 2006 to December 2009, were retrospectively analyzed. Specimens were cultured using optimal aerobic and anaerobic microbiological techniques. The antibiotic susceptibility test was carried out using the methods recommended by the Clinical and Laboratory Standards Institute. One specimen per patient was analyzed.

RESULTS

Of the 114 patients, 107 (93.8%) non-lactating and 7 (6.1%) lactating women were diagnosed with breast abscess during this period. Of the 114 specimens, 83 (73%) yielded bacterial growth. Of these, 115 pathogens were isolated with an average of 1.4 pathogens per abscess. Eighteen (22%) of the 83 specimens yielded mixed bacterial growth. There were more Gram-positive pathogens (60, 52%) than anaerobes (32, 28%) and Gram-negative pathogens (22, 19%). The predominant organisms were methicillin-susceptible Staphylococcus aureus (37, 32%), methicillin-resistant S. aureus (MRSA; 11, 10%), Bacteroides spp. (16, 14%), anaerobic streptococci (14, 12%) and Pseudomonas aeruginosa (9, 8%). Of the 48 S. aureus, MRSA accounted for 11 (23%). All MRSA isolates were susceptible to trimethoprim-sulfamethoxazole and vancomycin.

CONCLUSION

S. aureus was the most common pathogenic organism isolated in breast abscesses at Al-Amiri Hospital, Kuwait, of which 23% were MRSA. Nearly a third of the cases were caused by anaerobes, particularly B. fragilis. The data present a basis for the formation of empirical antimicrobial therapeutic policy in the management of breast abscess.