Breast abscess: Clinical sciences

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Introduction0:00–1:20

A breast abscess occurs when a bacterial infection forms a collection of purulent fluid, or pus, which leads to the development of a painful mass in the breast tissue.
It is most often a complication of mastitis, which involves inflammation and infection of the breast. Most cases of mastitis are lactational or puerperal, resulting from prolonged milk stasis, engorgement, and the entry of bacteria through breaks in the nipple.
Rarely, mastitis can be non-lactational or non-puerperal, which can be idiopathic, related to malignancy, or due to infection from recent surgery, nipple piercings, tattoos, or other trauma.
A breast abscess is more likely to occur in patients who smoke, have diabetes, or can even be a sign of a more serious pathology like inflammatory breast cancer.
Most cases are usually caused by methicillin-sensitive Staphylococcus aureus, while other bacteria like Streptococci sp., Staphylococcus epidermidis, and methicillin-resistant Staphylococcus aureus or MRSA may also be implicated.
Alright, when assessing a patient who presents with a chief concern suggesting a skin abscess, you should first perform an ABCDE assessment to determine if your patient is unstable or stable.

Unstable Patient1:20–2:01

If the patient is unstable, stabilize the airway and breathing first. Next, address circulation by obtaining IV access and initiating IV fluids for resuscitation.
Here’s a clinical pearl! Keep in mind that it’s very rare for breast abscess to be the sole cause of hemodynamic instability.
Thus, if the patient is unstable, then they’ve likely developed sepsis or even septic shock. Okay, now that you have taken care of your unstable patients, let’s talk about stable patients.

Stable Patient2:01–2:58

Your first step is to obtain a focused history and physical examination. Your patient will usually report breast pain, swelling, and purulent discharge from the nipple or from a lesion on the skin.
Make sure to ask about risk factors like a history of smoking, diabetes, recent childbirth, and if they are currently breastfeeding.When it comes to the physical exam, it might reveal increased warmth over the affected area, as well as erythema, and possible edema.
Additionally, you might feel a fluctuant, tender, or palpable mass. Patients also often present with fever.
If any of these signs and symptoms are present, you are likely dealing with a breast abscess.Okay, now that the diagnosis is made, let’s talk about the management.

Management2:58–5:06

This includes empiric antibiotics and pain medications. Penicillinase-resistant penicillins like dicloxacillin, or a first-generation cephalosporin is the antibiotic of choice, but for patients with beta-lactam hypersensitivity, or if MRSA is suspected, you can use clindamycin instead.
As for pain management, non-opioid pain medications like acetaminophen or ibuprofen should provide adequate relief. Then, a breast ultrasound should be obtained to estimate the size and evaluate for a drainable fluid collection.
Abscesses smaller than 5 cm require ultrasound-guided needle aspiration. The aspirate, and breast milk for lactating patients, should be sent for culture and sensitivity in order to provide better antimicrobial coverage.
You may repeat the needle aspiration every two to three days until there is no fluid collection visible on ultrasound. Lastly, patients in whom aspiration failed, or those with abscesses larger than 5 cm, should be treated with incision and drainage.Here’s a clinical pearl!
In case of lactational breast abscesses, the patient should be encouraged to continue breastfeeding or pumping breast milk even while they are undergoing treatment for their breast abscess, unless contraindicated when the antibiotic is unsafe for newborns.
Draining milk from the affected ducts will decrease pressure and helps resolve the infection. When it comes to the non-lactational breast abscesses, they can be the result of a malignancy, so be sure to investigate that as well once the acute inflammation has resolved.
Okay, now that the treatment is started, it’s time to assess the response. This should be done within three to five days.

Assess Response to Therapy5:06–6:27

If your patient shows an adequate response to the antibiotics and their signs and symptoms are gradually improving, complete the antibiotic course for a total of 10 to 14 days.
On the other hand, your patient is considered to have an inadequate response if they show continued purulent drainage, erythema that’s not receding, or still have a fever.
In that case, you need to re-evaluate and assess the skin appearance around the abscess. If there are no signs of ischemia or necrosis, you may consider repeating an ultrasound-guided needle aspiration or surgical incision and drainage of the abscess.
Finally, these patients should get a work-up to assess for inflammatory breast cancer. On the other hand, if there are signs of skin ischemia or necrosis, you should proceed with surgical incision and drainage, as well as debridement of the necrotic tissue.
And again, initiate the work-up for inflammatory breast cancer.Alright, as a quick recap… A breast abscess is a collection of purulent fluid which leads to the development of a painful mass in the breast tissue and most frequently occurs among lactating patients.

Review6:27–7:28

Initial management involves empiric antibiotics, pain medications, and ultrasound to determine the size, followed by ultrasound-guided needle aspiration or surgical incision and drainage, and reassessment within a few days.
If there’s an improvement, you can complete the antibiotic course. However, if there’s no improvement, you need to re-evaluate the skin for ischemia or necrosis.
If there are no signs of ischemia or necrosis, repeat an ultrasound-guided needle aspiration or surgical incision and drainage.
However, if you see skin ischemia or necrosis, proceed with surgical incision, and drainage, as well as debridement; and investigate the possibility