A breast abscess is often characterized as a consequence of delayed or insufficient
treatment following mastitis. The global prevalence of primary breast abscess in
lactating women is estimated to be around 11%. In developing countries, where the quality
of life and access to medical care may be limited, the prevalence of breast abscess tends
to be higher. For instance, in Pakistan, the occurrence of breast abscess reaches up to
16%.
This condition typically arises due to local inflammation and/or infection of the
terminal lactiferous ducts. Mastitis, a precursor to breast abscess, can be attributed to
factors such as poor hygiene, inadequate breastfeeding practices, milk stasis, cracked
nipples, and the colonization of Staphylococcus aureus. Patients with breast abscess
typically present with a painful, tender, and either focally or diffusely swollen breast.
It is noteworthy that breast abscesses can be broadly classified into lactational and
non-lactational types, each contributing significantly to morbidity in adult women.
Several risk factors contribute to the development of both primary and recurrent
lactational breast abscesses. These include increasing maternal age, obesity,
primiparity, diabetes, smoking, and a history of mastitis. Additionally, rare
predisposing factors encompass breast trauma, duct ectasia, fat necrosis, nipple
piercing, and breast cancer.
Staphylococcus aureus remains the most common causative organism, although E. Coli and H.
Influenza have also been identified. Of particular concern is the rising prevalence of
Methicillin-Resistant Staphylococcus Aureus (MRSA).The traditional approach to managing
breast abscesses involves Incision & Drainage (I&D) accompanied by antibiotic
therapy. However, this method is primarily reserved for complicated cases with skin
changes such as ulceration, necrosis, or recurrent abscesses. In recent years, needle
aspiration has emerged as the preferred treatment for uncomplicated cases. Clinical
examination and radiological assessments using ultrasound or CT are crucial for
establishing the diagnosis. Notably, the breast surgery community increasingly adopts
needle aspiration as a minimally invasive technique for cases where the abscess size is
less than 5cm on ultrasound, and symptoms have persisted for up to 5 days. Needle
aspiration offers advantages such as avoiding hospital stays,eliminating the need for
general anesthesia, and allowing continued breast feeding. It also reduces the risk of
complications like milk fistulae. Factors such as multiple dressings for wound care,
pain, dissatisfaction with cosmetic results, and delayed healing with I&D contribute
to the growing acceptance of aspiration as a suitable alternative.
Effective antimicrobial therapy is integral to the treatment of breast abscesses. Post
I&D, antibiotic coverage is mandated for preventing Surgical Site Infection (SSI).
The success of aspiration, similarly, hinges on judicious antimicrobial treatment. In an
era marked by antibiotic resistance, providing effective and targeted antimicrobial
therapy becomes crucial.
Studies highlight the benefits of local instillation of antibiotics, demonstrating
promising results in preventing SSIs and managing wounds and abscesses. Local
instillation not only provides bypasses systemic administration but also reduces the need
for postoperative systemic antibiotics. The concentration of antibiotics at the local
site is higher when instilled locally, as evidenced by in vitro studies showing a 100%
kill rate after only 60 seconds of exposure to the antibiotic irrigating solution. With
advancement and diversity in the field of surgery, it is adapting to minimally invasive
procedures with efficient out comes and conserving cosmetics. Aspiration for breast
abscesses is replacing the conventional I&D to provide better care, fewer
complications and better cosmetic results. In stemming the rise of resistance patterns
antimicrobial stewardship has become surgical obligation. Some studies show that
aspiration of the breast abscess with systemic antibiotics has a success rate of up to
94%, around 50%- 60% of the cases are recovered after single aspiration while some
20%-30% required a second time and rest needed multiple aspirations. The use of local
instillation of antibiotics adjunct to aspiration in management of breast abscess may
help limit the number of aspirations and recurrence, providing better cure and healing
time for the patients. Abscess wall and edema makes it take longer to achieve MIC
(minimal inhibitory concentration) than the local instillation. It can also help to limit
the use of systemic antibiotics, and promote continued breast feeding. Combined they can
not only cut down the morbidity but also prove to be better in treating the breast
abscess and a key step against the emerging antibiotic resistance.