Breast abscess is an acute inflammatory process resulting in the formation of a collection of purulent material (pus) in breast tissue. Characterized by a painful, erythematous mass formation in the breast, occasionally draining through the overlying skin or nipple duct.

Subareolar abscess

Lactational or puerperal abscess

• Painful, erythematous induration involving breast and leading to fluctuant, possibly palpable abscess
• Systemic symptoms: Fever and malaise
• Note that mastitis and abscess can occur either sequentially or concurrently

• Lactational abscess: Milk stasis (from blockage, fewer feedings, excess supply, weaning, etc.) and bacterial infection leading to mastitis and then abscess, with Staphylococcus aureus (commonly methicillin-resistant S. aureus [MRSA]) the most common causative agent. Group A Streptococcus, group B Streptococcus, and corynebacteria also commonly encountered
• Subareolar abscess:
  1. Central ducts involved, with obstructive nipple duct changes leading to bacterial infection
  2. Cultured polymicrobial organisms, including anaerobes, staphylococci, streptococci, and others

• Galactocele
• Inflammatory carcinoma
• Advanced carcinoma with erythema, edema, and/or ulceration
• Tuberculous abscess (rare in the U.S.)
• Hidradenitis of breast skin
• Sebaceous cyst with infection
• Plugged milk duct

• Clinical examination
• Ultrasound to identify fluid collection, which can be used to guide treatment options such as facilitating aspiration
• If abscess suspected, referral to surgeon for incision, drainage, and biopsy

• Perform culture and sensitivity test of abscess contents.
• If mammogram or ultrasound is required but prevented by discomfort, perform after treatment and subsequent resolution of abscess.

• Established abscess: Incision and drainage (I&D) vs. needle aspiration (latter usually with ultrasound guidance; typically requires multiple procedures for resolution)
  1. High likelihood of patients treated with aspiration subsequently requiring I&D
• Biopsy of abscess cavity wall to exclude carcinoma

• Antibiotics: Generally targeting staphylococci (S. aureus) for lactational abscess. Recommended initial antibiotic therapy is nafcillin or oxacillin 2 g q4h IV or cefazolin 1 g q8h IV for 10 to 14 days. Alternative includes vancomycin 1 g IV q12h.
• Outpatient management with dicloxacillin 500 mg q6h PO or cephalexin 500 mg q6h PO is reasonable for uncomplicated cases without suspicion for MRSA.
• If acute mastitis is identified and treated early without the development of an abscess, resolution without drainage is possible.
• Subareolar abscess: Broad-spectrum antibiotic treatment (e.g., cephalexin 500 mg PO qid or cefazolin 1 g q8h IV for 10 to 14 days for more severe infection) and drainage are needed to control acute phase. If abscess is odoriferous, consider anaerobes as most likely etiology and add metronidazole 500 mg PO/IV tid. Augmentin and clindamycin are reasonable alternatives in this situation.

Further surgical treatment for recurrences or fistula

• Lactational abscess: Possible to continue breastfeeding without risk of infection to the infant
• Subareolar abscess:
  1. High risk for recurrence or complication of fistula formation
  2. I&D often associated with poor cosmetic outcome
  3. Patient informed and referred to General Surgery for evaluation and treatment

1. If abscess drainage required
2. If subareolar abscess involved, refer to surgery

Breast Abscess (Patient Information)

Breast Cancer (Related Key Topic)

Mastodynia (Related Key Topic)