The patient will usually provide a history of breast pain, erythema, warmth, and possibly edema. Patients may provide lactation history. It is important to ask about any history of prior breast infections and the previous treatment. Patients may also complain of fever, nausea, vomiting, purulent drainage from the nipple or site of erythema. It is also important to ask about the patient's medical history, including diabetes. The majority of postpartum mastitis are seen within 6 weeks of while breast-feeding

On exam, the patient will have erythema, induration, warmth, and tenderness to palpation at the site in question. It may feel like there is a palpable mass or area of fluctuance. There may be purulent discharge at the nipple or site of fluctuance. The patient may also have reactive axillary adenopathy. The patient may have a fever or tachycardia on the exam, although these are less common.

The cornerstone of diagnosis of a breast abscess is the physical exam. A complete blood count may be obtained to evaluate for leukocytosis, but it is not necessary. If there is any frank drainage, cultures can be obtained to help guide antibiotic treatment. A breast ultrasound may be obtained if there is a question of cellulitis versus abscess, to evaluate for a drainable fluid collection. On ultrasound, abscesses may appear as ill-defined masses with internal septations.

In some cases, to confirm the presence of a  breast abscess, needle aspiration is done and the fluid analyzed.

Incision and drainage are the standard of care for breast abscesses. If the patient is seen in a primary care setting by a provider that is not comfortable in performing these procedures, the patient may be started on antibiotics and referred to a general surgeon for definitive treatment. Needle aspiration may be attempted for abscesses smaller than 3 cm or in lactational abscesses. Non-lactational abscesses have a higher rate of recurrence and often require multiple drainage procedures. Incision and drainage have lower recurrence rates, but they are more invasive than needle aspiration and may lead to scarring and possible poor cosmesis. If there is a recurrence of an abscess after needle aspiration, incision and drainage should be performed. If there is a large cavity follow incision and drainage, packing of the cavity may be done to promote further drainage and prevent the skin incision from healing before drainage is complete. Typically, these wounds heal fairly quickly. If the cause of the abscess is an obstructed or ectatic lactiferous duct, surgical excision may be necessary.[2][8]

A course of antibiotics may be given before or following drainage of breast abscesses. There are many options for treatment, and consideration must be given to the possible pathogens involved based on the patient's history. It is also important to consider if the patient is breastfeeding and whether the antibiotics given are safe in breastfeeding patients. Cultures should be obtained to guide antibiotic therapy, especially in recurrent breast abscesses. Some of the antibiotics to be considered are nafcillin, Augmentin, doxycycline, Trimethoprim, clindamycin, or vancomycin. Antibiotics may be required for 4-7 days

Patients with large breast abscesses or signs of sepsis should be considered for admission to the hospital. Large breast abscesses may need incision and drainage in the operating room, packing of the wound for healing by secondary intention, and possibly intravenous antibiotics.

Pain control with NSAIDs and/or prescription narcotics should also be considered.

If a breast abscess has been diagnosed, the infant should not be breastfed on that breast so as to prevent transmission of the infection.

• Benign or malignant breast mass
• Inflammatory breast cancer
• Cellulitis

The majority of isolated cases of breast abscess have good outcomes but in women with recurrent infections, it can lead to pain, scarring and a poor quality of life.

Most patients have recovery within 2-3 weeks following mastitis. Any patient that continues to have features of mastitis after 5 weeks should be evaluated for malignancy or infection.

The majority of breast abscess tend to occur in the postpartum period and if it is seen in a nonlactating female, the onus is on the clinician to rule out inflammatory breast cancer, new onset diabetes or infection with Mycobacterium.

• Scarring
• Breast asymmetry
• Pain
• Fistula
• Retraction of nipple areola complex leading to cosmetic deformity

Once the breast abscess is drained, the pain will quickly subside. Some patients may need NSAIDs for pain. In addition, one can apply a warm compress to soothe the inflammation and use moisturizer to prevent cracking of the nipples.

• Radiologist
• Surgeon
• Lactation Nurse

The patient should be educated on nipple and hand hygiene and prevent engorgement of the breast.

Patients may have recurrent or chronic infections, which can lead to chronic pain and scarring. In nonlactating women presenting with signs or symptoms of non-resolving breast abscess, a high index of suspicion for inflammatory breast cancer should be present. Patients should also be screened for new-onset diabetes.

Neonatal mastitis occurs in term or near-term infants. It is twice as common in females, and approximately 50% of these cases progress to breast abscess formation.

Other causes of breast abscesses include infected sebaceous cysts and hidradenitis suppurative, have specific evaluation and treatment.

There is no longer any question that breastfeeding has many health benefits for both the mother and the infant. In fact, the WHO recommends exclusive breastfeeding for the first six months of life and if possible, continue breastfeeding to age 18 months. Unfortunately, many women stop breastfeeding in the postpartum period because of the development of breast abscesses. The treatment of a breast abscess is usually with antibiotics, image-based aspiration, or incision and drainage.[9]

While a breast abscess may sound like a trivial localized infection, there are no standard guidelines on its management. With the specialization of breast surgeons, many patients are needlessly admitted to the hospital and undergo unnecessary surgical procedures. Further, because of the nonuniformity in management, recurrence rates of breast abscess are also high. Because of nonuniformity in managing these patients, the outcomes also vary. [10] [1]  To lower health care costs and reduce the morbidity of unnecessary surgery, it is recommended that a streamlined approach with an interprofessional team be involved in the management of these patients. The use of an interprofessional team should include the following:

• A radiologist to help make the diagnosis through imaging and perhaps aspirate the abscess
• Consult with a general surgeon on the management of a multiloculated abscess
• Infectious disease and pharmacist consultation to determine the choice of antibiotics
• Lactation nurse to educate the patient on nipple hygiene, hand washing, and preventing engorgement of the breast
• Nurse practitioner to monitor the patient in an outpatient setting to ensure that the breast abscess is resolving. If the condition persists, one should always consider ruling out infection, malignancy or a granulomatous disorder.

With an interprofessional approach to management, the treatment for a breast abscess can be optimized as an outpatient, leading to lower healthcare costs. In addition, the risks of missing an unknown breast mass like a cancer are also reduced because the patient is seen and examined by a team of healthcare professionals.

Outcomes and Evidence-based Medicine

Because of the heterogeneity in management methods of breast abscess, there is in fact not enough data to state if needle aspiration is a better option than incision and drainage for a breast abscess. It is not known if an antibiotic should always be administered to women undergoing incision and drainage or aspiration. The few case series available reveal that the outcome for most women is excellent with any of these methods, but it is not known which is superior. However, with all three methods, recurrence of breast abscess is common. Thus, it is highly recommended that a standardized interprofessional approach be developed to manage breast abscess, lower the rates of recurrence, and improve outcomes.

With the lack of evidence-based medicine, it is important to err on the side of aspiration and prevent the empirical prescribing of antibiotics. Surgery should only be a last resort option in complex cases.[9][7]