Management of Breast Abscess by Needle Aspiration 

 

Oliver S Leyson, MD

Alfonso Nunez, MD FPCS

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Departments of Surgery

_____________________________________

Reprint requests: Oliver Leyson MD, Department of Surgery, Hospital X, Quirino Avenue, Malate, Manila, Philippines

Email: ommcsurgery@yahoogroups.com

Abstract

Background: Breast abscess may be treated by either incision and drainage and antibiotics or by needle aspiration and antibiotics. Objective: to determine the effectiveness of needle aspiration in the management of breast abscess. Methods: All female patients, regardless of age, who sought consult from January-September 2004 with unruptured breast abscess 10 cm or less were subjected to needle aspiration.   Result: Total of 42 breast abscesses was accrued and the patients average age was 29.1years.  Eighteen (42%) patients were lactating and 24(57%) patients were not lactating. Overall, 31 (74%) patients had objective improvement and resolution of the abscess with a single aspiration treatment and four (10%) patients required multiple needle aspirations. Six (14%) required incision and drainage for progressive type of breast abscess.  One patient developed a recurrent breast abscess after a previously resolved breast abscess. Conclusion: Needle aspiration with oral antibiotic treatment could be the initially tried for breast abscess less than 10 cm.

Key words: Needle aspiration; breast abscess; lactation

Introduction

Breast abscess is an accumulation of pus in the breast tissue which was usually preceded by infection of the breast (mastitis). Breast infections are usually caused by bacteria common found on normal skin. Infections occur mostly in breastfeeding mothers but there is report of non-lactating women who developed abscess (1). The bacteria enter through a break in the skin, usually a cracked nipple during the early days of breastfeeding. The infected area becomes filled with pus.

In the Department of Surgery at hospital X, breast abscesses are treated with traditional management which included hospital admission, intravenous antibiotics and incision and drainage which was usually done at the operating room under general anesthesia. 

This study was done to assess the effectiveness of needle aspiration in the treatment of breast abscess both in lactating and non-lactating women in patients of hospital X. 

Methods:

 All female patients, regardless of age, with unruptured breast abscess less that 10 cm in diameter and lactating status, who sought consult from January -September 2004 to our Hospital X were included in the study. The size of the breast abscess was measured in centimeters including the indurated and erythematous areas.  Informed consent was obtained from all patients. Needle aspiration was done on all subjects using a hypodermic needle gauge 19 and a 20 ml syringe.   All patients were given cloxacillin 500mg capsule every six hours for seven days and mefenamic Acid 500 mg tablet every 8 hours for pain. All patients were followed up weekly until abscesses either resolved or progressed. All were treated on an outpatients basis.  No culture was done. For the lactating patients encouraged to continue breastfeeding from either breast and were not given lactation suppressants. Patients with chronic breast abscesses and cancer were exclude.

 Patients were followed up using the “follow-up” scheme (see appendix 1).

 Management Action Plan for Patients After 1 week Follow up

I. Resolved - Another follow up 1 week after complete resolution and treatment. (2 weeks)

II. Resolving – Patient will have to continue antibiotics for 7 days more. Advised patient to follow up after a week.

III. Persistent – Repeat aspiration and continue antibiotics for 1 week more. Reclassify patient after the subsequent follow up.

IV. Progressing- Admit patient for definite incision and drainage.

V. Ruptured-continue antibiotics and dressing for 1 week more. 

VI. Recurrent- Initial follow up of patient resolved breast abscess but recurred after a week of follow up.

 Results  

            A total of 42 breast abscesses was accrued and the average age of patients were 28.3 years with a range 6-42.  Eighteen (42%) patients were lactating and 24(57%) patients were non-lactating.  The size of the breast abscess range from 2-10 cm with a mean of 5.9  cm (Table 1).

Overall, 31 (74%) patients had objective improvement and resolution of the abscess with a single aspiration treatment, four (10%) patients required multiple needle aspirations. Six (14%) required incision and drainage for progressive type of breast abscess (Table 2).

Breast abscess was noted in 24 (57%) of the non-lactating group (NLG), while 18 (43%) on the lactating group (LG).   In the NLG,12 (29%) resolved with single aspiration after one week follow up, eight (33%) patients resolved after two weeks of antibiotic and daily wound care and 4 (10%) progressed after 2 weeks of follow up and was subsequently admitted for a definitive incision and drainage (Table 3).

In the LG, 7 (17%) patients were classified as resolving type of breast abscess wherein medications were continued, 6 (14%) patients were classified as persistent type of breast abscess and underwent repeated aspiration.  In this group complete resolution was noted after 3 weeks of follow up.  Those classified classified as progressive type of breast abscess 2 (5%) patients were admitted for a definitive incision and drainage.  Those classified to have ruptured breast abscess 2 (5%), medications were continued and daily wound care were rendered (Table 2).

One (2.4%) patient developed a recurrent breast abscess after a previous resolved breast abscess on the same breast among the lactating group. Repeat aspiration was done and medications were continued.

Discussion

In a study done by Schwartz and Shrestha , needle aspiration and oral antibiotic treatment of breast abscesses on an outpatient basis were safe and useful. They were successful 18(82%) out of 33 patient with a single aspiration.  Incision and drainage needs daily wound dressing oftentimes left with unacceptable scar formation. However, the fear of pain and discomfort during and after the procedure often prompts surgeons to shy away from a less aggressive surgery such as needle aspiration (1). 

In 1993, Kartsup et al, successfully treated 19 consecutive lactating breast abscess with ultrasound guided percutaneous drainage and the result was 95% success rate with only one patient needed incision and drainage(2).

In this study we demonstrated 74% effectiveness of needle aspiration in patients with breast abscess less than 10 cm. There was no need for general anesthesia or operation, no in-hospital stay, postoperative dressings and discomfort. With the increasing concern of the need for cost-effective treatment worldwide, the savings following aspiration therapy were considerable because surgery was eliminated and only minimal post treatment care was needed.

Needle aspiration and oral antibiotic treatment of breast abscesses less than 10 cm could be initially tried with the use of the following monitoring scheme.

References

1.      Schwarz, RJ; Shrestha, R. Needle aspiration of breast abscesses. Am J Surg. 2001; 182(2) 117-119.

2.      Karstrup S; Solvig J; Nolsoe CP; Nilsson P; Khattar S; Loren I; Nilsson A; Court-Payen M. Acute puerperal breast abscesses: US-guided drainage. Radiology. 1993; 188(3): 807-9.

3.      O’Hara RJ; Dexter SP, Fox JN. Conservative management of infective mastitis and breast abscesses after ultrasonographic assessment. Br J Surg. 1996; 83(10):1413.

4.      Tan,SM; Low,SC. Non-operative treatment of breast abscesses. Aust-New- Zealand J  Surg.1998; 68(4):423-24.

Table 1. Characteristic of patients included in the study.

 Table 2. Results of needle aspiration of breast abscess.

 Table 3. Classification of Breast Abscess.

 Definition of Terms:

Breast Abscess - Collection of pus usually localized. Can be associated with

lactation or fistulous tracts secondary to squamous epithelial neoplasm or duct occlusion.

Resolved Breast Abscess   Complete resolution after 1 week of treatment.

Resolving Breast Abscess Decreased erythema and indurations compared to

the initial consult.

Persistent Breast Abscess no resolutions from the initial consult same size and

indurations (compare pictures from initial consult)

Progressing Breast Abscess Increase in size and indurations.

Ruptured Breast Abscess Presence of drainage after follows up

Recurrent Breast Abscess– previously resolved breast abscess but recurred

after resolution.

Appendix 1

Follow up scheme of patients with breast abscess

I.  Resolved - complete resolution after 1 week of treatment.

II. Resolving - decreased erythema and indurations compared to the initial consult.

III. Persistent - no resolution from the initial consult same size and indurations (compare from initial consult)

IV. Progressing- increase in size and indurations.

V. Ruptured- presence of drainage after follow up. 

VI. Recurrent - Initial follow up of patient resolved breast abscess but recurred after a week of follow up.