Breast Abscess

Breast Abscess is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Localized accumulation of infected fluid within the breast parenchyma
  • Can be associated with lactation or fistulous tracts secondary to squamous epithelial neoplasm or duct occlusion
  • System(s) affected: skin/exocrine, immune
  • Synonym(s): mammary abscess; peripheral breast abscess; subareolar abscess; puerperal abscess

Pregnancy Considerations
Most commonly associated with postpartum lactation

Epidemiology

  • Predominantly reproductive age and perimenopausal
    • Puerperal abscess: lactational
    • Subareolar abscess: perimenopause to postmenopause (1)
  • Predominant sex: female
  • Higher incidence in African American women, diabetics, smokers

Incidence
  • Ranges from 0.4% to 11% of breastfeeding women; the Academy of Breastfeeding Medicine cites 3% (1,2).
  • Puerperal abscess has highest incidence within 6 weeks postpartum and while weaning from breastfeeding (2).

Etiology and Pathophysiology

  • Puerperal abscesses:
    • Insufficient treatment of mastitis
    • Unattended postpartum engorgement
    • Plugged lactiferous duct causing stasis, leading to microbial growth and secondary abscess formation
  • Subareolar abscess: associated with squamous metaplasia of the lactiferous duct epithelium, keratin plugs, ductal ectasia, fistula formation (1)
  • Microbiology
    • Staphylococcus aureus is most common cause.
    • Less common causes
      • Streptococcus pyogenes, Escherichia coli, Bacteroides
      • Corynebacterium
      • Pseudomonas
      • Proteus
    • Methicillin-resistant S. aureus (MRSA) is a significant cause.

Risk Factors

  • Maternal age >30 (3)
  • Primiparous (3)
  • Gestational age ≥41 weeks (3)
  • Puerperal mastitis
    • Up to 11% progression to abscess (4)
    • Most often due to inadequate therapy
    • Risk factors (stasis):
      • Infrequent or missed feeds
      • Poor latch (1)
      • Damage or irritation of the nipple
      • Suboptimal use of breast pump
      • Illness in mother or baby
      • Rapid weaning; plugged duct
      • Mother employed outside the home (4)
      • Breastfeeding difficulties identified by in- hospital lactation consultant (4)
  • General risk factors
    • Smoking
    • Diabetes
    • Obesity
    • Rheumatoid arthritis
  • Medically related risk factors
    • Steroids
    • Silicone/paraffin implant
    • Lumpectomy with radiation
    • Inadequate antibiotics to treat mastitis
    • Topical antifungal medication used for mastitis
  • Nipple retraction
  • Nipple piercing (mastitis, subareolar abscess)
  • Higher recurrence rate if polymicrobial abscess

General Prevention

  • Frequent breast emptying with on-demand feeding and/or pumping to prevent mastitis
  • Early treatment of mastitis with milk expression, antibiotics, and compresses
  • Smoking cessation to minimize occurrence/recurrence

Commonly Associated Conditions

Lactation, weaning

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