Special Report

Breast abscess: evidence

based management
recommendations
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Expert Rev. Anti Infect. Ther. 12(7), 753–762 (2014)

Elaine Lam,
Tiffany Chan and
Sam M Wiseman*
Department of Surgery, St Paul’s
Hospital and University of British
Columbia, Vancouver, BC, Canada
*Author for correspondence:
Tel.: +1 604 806 9108
Fax: +1 604 806 9957
smwiseman@providencehealth.bc.ca
For personal use only.
Literature review was carried out and studies reporting on treatment of breast abscesses
were critically appraised for quality and their level of evidence using the Strength of
Recommendation Taxonomy guidelines, and key recommendations were summarized. Needle
aspiration either with or without ultrasound guidance should be employed as first line
treatment of breast abscesses. This approach has the potential benefits of: superior cosmesis,
shorter healing time, and avoidance of general anaesthesia. Multiple aspiration sessions may
be required for cure. Ultrasound-guided percutaneous catheter placement may be considered
as an alternative approach for treatment of larger abscesses (>3 cm). Surgical incision and
drainage should be considered for first line therapy in large (>5 cm), multiloculated, or long
standing abscesses, or if percutaneous drainage is unsuccessful. All patients should be treated
concurrently with antibiotics. Patients with recurrent subareolar abscesses and fistulas should

be referred for consideration of surgical treatment.

KEYWORDS: breast abscess • breast infection • incision and drainage • mastitis • percutaneous drainage

Breast abscesses are most commonly diagnosed

in young women who are lactating, though non-
lactational abscesses are also diagnosed in older
women toward the end of their reproductive
years. Patients may present to a variety of health
care providers including their family physician,
the emergency room or surgical clinics. Early rec-
ognition and timely referral for management are
necessary to prevent evolution to severe infection
and sepsis. However, lack of consensus regarding
best management practices may lead to delays in
treatment and worsened outcome. Common
modalities of treatment include antibiotics, per-
cutaneous aspiration and surgical incision and
drainage (I & D). Despite the common occur-
rence of breast abscesses, there are few random-
ized trials evaluating their treatment, which
emphasize the need for a critical review and sum-
mary of the available evidence to guide decision-
making. Advances in quality and availability of
ultrasound are also allowing for timely access to
successful treatment, even for large abscesses,
with less invasive techniques. The objective of
this review is to evaluate current available evi-
dence and provide graded recommendations for
clinicians regarding the management of breast
abscesses. Key studies are summarized in TABLE 1.
Epidemiology
A breast abscess is defined as a localized col-
lection of purulent material within the
breast [1]. Breast abscesses in lactating and
in nonlactating women are two distinct clin-
ical entities, each with a discrete pathogene-
sis. Breast infections are the most common
benign breast problem during pregnancy
and the puerperium [2]. The incidence of
lactational, or puerperal, breast abscesses
ranges from 0.4 to 11% and tend to occur
in younger women during their reproductive
years [3]. Lactational breast abscesses are
more common than nonlactational breast
abscesses although the incidence of lac-
tational abscesses has been decreasing over
time [3,4].
Nonlactational breast abscesses are relatively
uncommon compared with lactational abscesses.
About 90% of nonpuerperal breast abscesses are
subareolar breast abscesses [5]. The remaining
nonlactational breast abscesses are caused by
rare granulomatous, bacterial or fungal etiolo-
gies. Nonlactational, subareolar abscesses tend
to occur in women toward the end of their
reproductive years [3].

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2014 Informa UK Ltd ISSN 1478-7210 753

 Special Report Lam, Chan & Wiseman
Table 1. Summary of key studies.
Study (year) Study design and interventions
Needle aspiration versus incision and drainage
Eryilmaz (2005) Randomized controlled trial
Clinical diagnosis of breast abscess, no
ultrasound
18G needle aspiration, repeated every
other day until completely resolved or
5 aspirations performed, if not resolved
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then I & D
Ampicillin–sulbactam 375 mg b.i.d. 
10 days. If >10 cm, then iv. route
initially  3 days
Ultrasound-guided percutaneous drainage
Chandika Randomized controlled Trial of
(2012) ultrasound guided aspiration vs I & D
Aspiration 16 G needle I & D under
general anesthetic
Cloxacillin 500 mg t.i.d.  10 days
Naeem (2012) Randomized controlled trial
For personal use only.
Aspiration method not described. I & D
under general anesthetic
Co-amoxiclav 625 mg t.i.d.,
metronidazole 400 mg daily until
cultures received
Ozseker (2008) Uncontrolled trial
Aspiration with 18–22G plus saline
irrigation. Follow-up ultrasound
2–4 days, reaspiration if abscess still
visible
Concurrent antibiotics and possibly plus
or minus intracavitary antibiotics
Elagili (2007) Uncontrolled trial
Aspiration 19–14G needle. 5-F catheter
placed in two patients for large
volumes of pus (>150 ml)
Cloxacillin 500 mg po. q.i.d.  7 days
Mammogram >35 years. Trucut biopsy
if mass persisted >7 days
Ultrasound-guided percutaneous catheter placement
Christensen Retrospective case series
et al. (2005) Ultrasound diagnosis
Aspiration with 0.8–1.2 mm needle. If
cavity >3 cm, insertion of 5.7F cathether
All procedures under local anesthesia.
Follow-up ultrasound every 2–3 days for
repeat aspiration or catheter left in place
Dicloxacillin 1 g t.i.d. (and metronidazole
500 mg t.i.d. for nonpuerperal abscess)
I & D: Incision and drainage.
754
Population Comments Ref.
characteristics
45 lactating women All patients in I & D group successfully [17]
(mean age 25 years) treated except 1 pt who had 12 cm
Mean abscess size 6 cm abscess who recurred at 2 months.
About 70% of patients were displeased
with cosmetic outcome
Mean aspirations 3.5 (range 1–5). About
14% single aspiration, 45% multiple
aspirations. About 41% required I & D
for nonresolution. Abscesses <5 cm all
treated with aspiration only. If >5 cm,
only 25% success
Follow-up throughout lactation period,
duration not specified
65 women >age 14 93.1% single aspiration, 69% [18]
Abscesses <5 cm by reaspiration. No conversion to I & D
ultrasound Mean duration of healing 24 days in
both groups
32 patients per arm. 40.6% required single aspiration and 1 [19]
Mean age 28.4 years week of antibiotics. 18.8% required
Only studied abscesses two aspirations, 34.4% multiple
<5 cm in women who aspirations and >1 week of antibiotics.
were not pregnant at the Two patients failed and managed with
time of study I & D. Mean healing time 45 days I & D
group vs 19.13 days needle aspiration
group. Follow-up 8 weeks, no recurrences
10 patients (mean age Abscesses <3 cm treated with single [23]
29 years) referred from aspiration and resolved. Mean number
ED of aspirations for remainder was 6.
11 abscesses (5 puerperal, About 91% resolved with aspirations
6 non-puerperal) and no surgical intervention. Average
3 patients (27%) length of symptoms 30 days. No
abscesses <3 cm recurrences in 6-month follow-up
30 female patients (mean 50% complete resolution with one [16]
age 31.9 years), aspiration, 23.3% two aspirations,
16 nonlactating, 10% three aspirations. About 13%
14 lactating referred for surgical drainage for
Median abscess size 4 cm multiloculated collections. Overall
(range 1–15 cm) aspiration success rate 83.3%. Average
length of symptoms 11.63 days. No
recurences after 12 weeks of follow up
151 women. 89 puerperal 86/89 (97%) puerperal and 50/62 (81%) [29]
(median age 32, range non-puerperal abscess successfully treated
15–42), 62 nonpuerperal after first drainage (range 1–6). 77 (87%)
(median age 42, range of catheter group treated as outpatients,
15–72) median duration 4 days (range 2–6 d).
Median abscess size 13 pts underwent surgical excision
puerperal 3.5 (1–8 cm), Median number of follow-up
nonpuerperal 2 (0.5–8 cm) ultrasound: puerperal 4 (range 1–10),
nonpuerperal 3 (1–7)
Expert Rev. Anti Infect. Ther. 12(7), (2014)
 Breast abscess Special Report

Table 1. Summary of key studies (cont.).

Study (year) Study design and interventions Population Comments Ref.
characteristics
Ultrasound-guided percutaneous catheter placement (cont.)
Berna-Serna Retrospective case series 39 patients (36 women, 19/22 single aspiration. 3/22 required [31]
(2004) Needle aspiration when abscess £3 cm, 3 men) repeat aspiration. 15/16 catheter
22–18G needle. Rpt US 48 h, 34 nonlactating, drainage resolution by 24 h
reaspiration if collection still evident 2 lactating women. Follow-up mean 8.4 months, range
Catheter drainage when >3 cm, 6F Mean age 28.9 years 2–48 months. Complete resolution
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pigtail. Aspiration and lavage with
sterile saline daily until no drainage and
US resolved
FNA + cytology if nonresolving mass
after 3 days
Antibiotics for mean 3.4 days
Amoxicillin/clavulanic acid (79.5%),
clindamycin (20.5%)
Ulitzsch (2004) Retrospective case series
Aspiration 21–14G needle. Abscesses
<3 cm aspiration and saline irrigation.
Follow-up ultrasound every 2–3 days
until resolution. Reaspiration if abscess
still visible
Abscesses ‡3 cm, 6–8F Cook catheter
aspirated and irrigated. Follow-up
For personal use only.
(range 12–54) between 2–4 weeks. Recurrence in
Mean abscess size 3.2 cm four patients, all recurrences treated
(range 1.2–6 cm) with surgery
108 consecutive lactating Repeat aspirations required in [30]
women 12/23 (52%), mean aspirations
Mean age 32 years (range 1.8 (range 1–5). 1 I & D performed in
20–39) aspiration group
Mean abscess size treated Average duration of catheter 6.4 days
by aspiration 2.2 cm (range 1–25 days). 5/33 (15%)
(range 1–4 cm) recurrence following catheter removal.
Mean abscess size treated All recurrence treated with catheter

2–3 days after with irrigation. Catheter
removed if <4 ml saline could be
instilled and abscess no longer visible
Survey for pt satisfaction
I & D: Incision and drainage.
by catheter 5.2 cm (range reinsertions (1) or needle aspiration (4).
3–10 cm) No surgical interventions
Survey 86% response rate. 95%
satisfaction with cosmetic result at
38–63 months after treatment

Pathogenesis & etiology
Lactational abscesses are due to progression of mastitis or lac-
tational breast inflammation [2]. Milk stasis provides a lactose-
rich culture medium for bacteria that are introduced through
the terminal ducts of the nipple [2]. This results in mastitis that
may progress into a breast abscess [2,6]. Puerperal mastitis affects
2% of lactating women [2]. The two principal types of mastitis
that may progress to abscess formation are epidemic mastitis
and endemic mastitis [6]. Epidemic mastitis is usually nosoco-
mial, often occurs approximately 2–3 days postpartum, and
will commonly progresses to abscess formation [6]. Staphylococ-
cus is the most common infective organism [6]. Endemic or
‘sporadic’ mastitis is generally less aggressive, usually occurs
after 1–2 weeks of nursing and rarely leads to abscess forma-
tion [2,6]. Staphylococcus aureus, staphylococcus epidermidis and
streptococci are the major contributing organisms [6].
Nonlactational, subareolar abscesses were first described by
Zuska et al. in 1951 as fistulas of lactiferous ducts that resulted in
chronically draining sinuses and abscess formation near the are-
ola [5,7]. This condition is associated with squamous metaplasia of
the lactiferous duct epithelium, duct obstruction and subareolar
duct dilation or duct ectasia [5,8,9]. This is followed by periductal
inflammation, infection of these terminal lactiferous ducts, duct
rupture and subsequent periareolar fistula and subareolar breast
abscess formation [5,9,10]. These abscesses are chronic in nature,
have recurrent obstruction of the ducts with keratin plugs and
have a tendency to form extensive fistulas [5,9]. Nonlactational
abscesses are associated with diabetes mellitus and smoking [1,10].
Clinical presentation & diagnosis
The clinical diagnosis of a breast abscesses is usually made
based on their clinical presentation and by an individual’s his-
tory with a breast abscess tending to present with pain and/or a
lump [6]. Lactating women may complain of breast engorge-
ment and may also present with recent or recurrent mastitis [8].
Women with nonlactational abscesses may have a history of
smoking or diabetes mellitus. The clinical presentation of breast
abscess also includes fever, chills and malaise.
Physical exam usually identifies pain, erythema and firmness
over an area of the breast at the location of the abscess. However,
a mass is not always readily palpable, especially if it is located
deep within a large breast [8]. Lactational breast abscesses tend to
be found peripherally in the breast, and nonlactational abscesses
are typically found in a periareolar or subareolar location [3].
Imaging studies may assist with the diagnosis of breast
abscesses. Abscesses may be detected and visualized by

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 Special Report Lam, Chan & Wiseman
ultrasound and have a variety of characteristic sonographic
findings [11]. Ultrasound is also useful to determine whether
there are multiple small abscesses or a single discrete cavity,
and whether the abscess is loculated or septated to assist with
treatment planning [11]. Mammography is inappropriate for the
diagnosis of breast abscesses because of edema and also because
a discrete abscess cavity within an area of breast pain, and
increased density from inflammation, may not be demon-
strated [11]. However, mammography is useful to investigate for
possible malignancy, including inflammatory breast cancer,
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which may require tissue biopsy for diagnosis [12].
It must be recognized that numerous other pathologies can
present in a similar manner to a breast abscess. The differential
diagnosis of a breast abscess includes: other infectious condi-
tions, malignancy, trauma, dermatologic conditions, venous
and lymphatic abnormalities or idiopathic causes [12]. These dif-
ferential diagnoses must be considered and investigated when
appropriate.
Review methodology
The terms breast abscess or subareolar abscess were combined
with treatment, management, aspiration, surgical, drainage or
antibiotics as keyword and subject heading searches in Medline
(OvidSP), Pubmed (OvidSP) and the Cochrane Database of
For personal use only.
Systematic Reviews up to February 2014. The Clinical Evi-
dence compendium by the BMJ Publishing Group was also
searched for breast abscess treatment guidelines.
Abstracts were screened for relevance to the topic. Full-text
articles were retrieved for the screened abstracts and reviewed to
determine the strength of evidence and suitably for inclusion in
management recommendations. Articles regarding breast abscesses
following surgical procedures such as implants or partial mastec-
tomy were excluded. Studies using patient-oriented evidence
measures were preferred over disease-oriented evidence measures
that may or may not reflect improvements in patient outcomes [13].
Recommendations were developed based on the highest quality
evidence available. The studies with the strongest methodologies,
including meta-analysis and randomized controlled trials, were
sought out. If these were not available, nonrandomized trials and
then observational studies were utilized. Case reports were not
included in developing the recommendations.
The strength of recommendation taxonomy (SORT) was
used to evaluate and grade the literature and the recommenda-
tions [13]. Individual studies were critically appraised for quality,
and their level of evidence (level 1, 2 or 3) was determined
according to SORT [13]. The strength of key recommendations
was evaluated based upon the quality, quantity and consistency
of the available body of evidence and graded (grade A, B or C)
according to SORT [13]. The key recommendations are summa-
rized in a SORT table (TABLE 2).
Treatment options
Surgical incision & drainage
Surgical incision and drainage, usually carried out under a gen-
eral anesthetic, has been the traditional method for treating
756
breast abscesses [3,4]. The most common technique involves
incision over the point of maximal swelling or fluctuance, digi-
tally breaking down any loculi and draining the purulent mate-
rial from within the cavity [14]. The cavity is then irrigated and
either, left open and packed with gauze, or its edges may be
loosely approximated around a drain. More radical surgical
therapy involves unroofing the abscess cavity to allow for con-
tinued drainage [14]. An alternative method described by
Benson et al. involves incision over the abscess, manually break-
ing down loculations, curettage of the wall of the abscess cavity
to remove its lining granulation tissue and then suturing closed
of the abscess cavity [15]. This technique of incision, drainage
and primary closure of the abscess cavity was compared retro-
spectively with incision, and drainage of the abscess cavity and
leaving the wound open to drain [15]. The mean time for heal-
ing was longer for the primary drainage group compared with
the sutured group although the rate of recurrence was similar
between both groups. A variety of other techniques for surgical
treatment of breast abscesses has been reported in the literature.
Surgical incision and drainage is the gold standard treatment to
which others have been compared. The decision as to which
technique should be employed is determined by the preference
and experience of the treating physician. There are currently no
randomized controlled studies comparing different surgical
methods for drainage of breast abscesses.
Percutaneous drainage
The traditional treatment of breast abscesses by surgical incision
and drainage has several potential disadvantages that include:
scar and poor cosmetic outcome, expense, requirement for gen-
eral anesthesia, need for regular postoperative dressing changes
and interference with lactation [16]. More recently, percutaneous
drainage of breast abscesses, using needle aspiration or the
insertion of a small calibre drain under local anesthesia, has
been studied as an alternative to surgical incision and drainage.
A randomized controlled trial comparing incision and drain-
age to needle aspiration without ultrasound guidance for the
treatment of breast abscesses during lactation reported lower
cure rates for abscesses treated with aspiration (59%) compared
with surgical incision and drainage (100%) [17]. As well, multi-
ple aspirations were often required prior to abscess resolu-
tion [17]. Risk factors for failure of needle aspiration included
abscesses larger than 5 cm (size determined clinically), larger
pus volume and longer duration of symptoms. However, the
healing time was significantly longer with incision and drainage
compared with needle aspiration, and most women expressed
dissatisfaction with the cosmetic outcome of incision and
drainage. Similarly, a randomized controlled trial reported by
Naeem found differences in healing time by as much as
25 days, with average healing time 45 days for surgical drainage
and 20 days for aspiration. The average incision size utilized is
not described in this study [18]. Another randomized clinical
trial reported in 2011 compared ultrasound-guided needle aspi-
ration to surgical drainage for abscesses smaller than 5 cm (as
measured with ultrasound) and found that while there was no
Expert Rev. Anti Infect. Ther. 12(7), (2014)
 Breast abscess Special Report

Table 2. Strength of recommendation taxonomy table of key recommendations.

Study (year) Key clinical recommendation Strength of Comment Ref.
recommendation
Percutaneous drainage
Elagili (2007), Needle aspiration either with or without B Consistent findings from [16–24]
Eryilmaz (2005), ultrasound guidance should be employed as levels 2 and 3 evidence
Chandika (2012), first-line treatment of breast abscesses with randomized controlled trial,
Naeem (2012), superior cosmesis, shorter healing time and controlled trial, uncontrolled
Dener (2003), no need for general anesthesia compared trials case series
Ozseker (2008), with surgical incision and drainage. Multiple
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Leborgne (2003) aspirations may be required to achieve

resolution
Fahrni (2012), Ultrasound-guided percutaneous catheter B Consistent findings from [25–31]
Hook (1999), placement may be considered as an levels 2 and 3 evidence:
Karstrup (1993), alternative for larger abscesses (>3 cm); case series
Karstrup (1990), however, this requires that the catheter be
Christensen et al. (2005), left in place and cared for by the patient or
Ulitzsch (2004), with home medical care
Berna-Serna (2004)

Elagili (2007), Surgical intervention with incision and B Consistent findings from [16,17,21,
Eryilmaz (2005), drainage are required if needle aspiration or levels 2 and 3 evidence: 23,25,26]
Schwarz (2001), catheter drainage is unsuccessful, and there randomized controlled trial,
Ozseker (2008), is progression of infection or sepsis. However, uncontrolled trials, case
Fahrni (2012), no ideal cutoff for the number of aspiration series
Hook (1999) attempts or other standardized criteria has
For personal use only.

been defined to determine when

percutaneous drainage should be abandoned
and surgical incision and drainage
undertaken. Consideration should be given to
surgical incision and drainage as first-line
therapy in larger (clinically >5 cm),
multiloculated, or longstanding abscesses
Surgical drainage
Scholefield (1987), Surgical incision and drainage of the abscess C Consistent findings from [4,14,15]
Bates (1973), or incision and primary suture closure of the level 3 evidence:
Benson (1970) abscess cavity are comparable techniques for retrospective case series
the surgical management of breast abscesses
Lactiferous duct excision for nonlactational subareolar abscesses
Lesanka Versluijs- Recurrent subareolar abscesses may require C Consistent findings from [5,9,34–37]
Ossewaarde (2005), surgical excision of major lactiferous ducts level 3 evidence:
Li (2006), and mammary fistulas. Patients with retrospective case series
Hanavadi (2005), recurrent subareolar abscesses and fistulas
Meguid (1995), should be referred to surgical specialists for
Ekland (1973), further surgical intervention
Lannin (2004)
Antimicrobial therapy
Zimmerman (2009), Empiric antibiotics should be given in C Consistent findings from [38–43]
Chuwa (2009), combination with abscess drainage in the level 3 evidence:
Stafford (2003), treatment of all breast abscesses. Empiric retrospective case series
Dabbas (2010), therapy for breast abscess should include and consensus guideline
Moazzez (2008), coverage for community-acquired MRSA
Gilbert (2010) depending on local resistance patterns
using clindamycin or trimethoprim–
sulfamethixazole. Cultures should be taken
at the time of aspiration or drainage.
Subsequent antimicrobial drug therapy
should be modified to ensure appropriate
bacterial coverage based on cultures and
sensitivity testing

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 Special Report Lam, Chan & Wiseman
difference in overall healing rate, needle aspiration was more cost-
effective [19]. Unfortunately, these randomized trials are small and
likely underpowered, and do not describe whether a standardized
surgical approach was employed in their study protocols [18,19].
A nonrandomized controlled trial comparing incision and drain-
age with serial needle aspirations in lactating women diagnosed
with breast abscesses found similar healing times between the two
groups with superior cosmesis in the needle aspiration group [20].
Uncontrolled trials using blind needle aspiration had cure rates
ranging from 82 to 100% when needle aspiration was used
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alone [21,22]. Late presentation (>6 days) and large volume of pus
output from first aspiration were significantly associated with a
failure to cure utilizing a needle aspiration technique [21].
Ultrasound may be used as a tool to guide needle aspiration
or catheter placement, in addition to its role in assisting with
breast abscess diagnosis. Uncontrolled trials reporting needle
aspiration of breast abscesses in both lactating and nonlactating
women reported success rates ranging from 83.3 to 91% [16,23].
A retrospective case series had consistent results and observed a
96% cure rate when using ultrasound-guided needle aspira-
tion [24]. Abscesses drained using ultrasound guidance also often
required multiple aspiration sessions [16,23]. In one retrospective
case series of 110 patients with a mean abscess size that was
2.1  2.7 cm, 29% of patients were treated successfully with
For personal use only.
antibiotics alone, 51% underwent ultrasound-guided aspiration
or catheter drainage, 11% had attempted percutaneous manage-
ment but then required surgery and 9% had primary surgery.
It is not specified what factors influenced their practice though
in general, aspiration alone was used to treat abscesses <3 cm
in size, while larger abscesses were drained with catheters. Only
9% of patients had abscess recurrence, and 10% of these
patients were treated primarily with surgery [25]. Multiloculated
abscesses are significantly associated with a failure to cure by
aspiration (~50% recurrence) [16]. Uncontrolled trials and retro-
spective case series have suggested that breast abscesses smaller
than 3 cm as measured by ultrasound, are more likely to
resolve after a single aspiration session and are less likely to
require surgical treatment compared with larger abscesses [23,26].
Although studies have been conducted evaluating the use of
ultrasound-guided needle aspiration for abscess drainage, there
are no studies directly comparing ultrasound-guided aspiration of
abscesses to blind abscess aspiration. There is also no evidence
available to determine whether ultrasound-guided aspiration is
superior to blind needle aspiration for breast abscess treatment.
Small calibre percutaneous catheters can also be inserted
under ultrasound guidance and left for continued drainage of
breast abscesses. The feasibility of percutaneous catheter drain-
age using ultrasound guidance for the treatment of breast
abscesses was first reported by Karstrup et al. in two small ret-
rospective case series with success rates of 95 and 100% [27,28].
Further studies including a retrospective case series and a pro-
spective clinical trial evaluated percutaneous drainage using
small calibre catheters. In these studies, both puerperal and
nonpuerperal abscesses ‡3 cm were percutaneously drained
under ultrasound guidance and connected to a closed drainage
758
system [29–31]. The catheters were left in situ and were cared for at
home by patients until they were removed. The catheters were
removed when there was clinical resolution of the infection and
local symptoms, no further drainage from the abscess cavity and
no residual fluid accumulation was seen by ultrasound. Needle
aspiration was used for abscesses <3 cm. In one report 97% of
patients with puerperal breast abscesses and 81% of patients with
nonpuerperal abscesses recovered after the first round of
ultrasound-guided drainage in a prospective uncontrolled clinical
trial [29]. Success rates of this strategy in retrospective case series
studies ranged from 96 to 100% for abscesses <3 cm treated with
needle aspiration and from 85 to 88.2% for abscesses ‡3 cm
treated with catheter placement [30,31]. The cutoff of 3 cm used in
these studies was based on observations from uncontrolled studies
that reported needle aspiration to be less successful for abscesses
smaller than 3 cm [21,23].
As none of the studies defined the specific criteria they uti-
lized prior to abandoning needle aspiration and proceeding
with surgical incision and drainage of the breast abscess, there
is a potential for study selection biases. The indications for sur-
gery after unsuccessful aspiration attempts included patient
preference and choice of the treating physician. There are no
studies that have determined the safest maximum number of
abscess aspirations that should be carried out prior to surgical
intervention. As well, the optimal frequency and time interval
between aspirations have also not been specifically evaluated.
Patient tolerance of multiple aspiration sessions and the poten-
tial progression of infection and sepsis, must be considered in
future study design. It is also important to note that all patients
in these studies were treated concurrently with antibiotics.
Lactiferous duct excision of nonlactational subareolar
abscesses
The chronic and recurrent nature of nonlactational subareolar
abscesses and their associated fistulization to lactiferous ducts,
as well as the development of chronically draining sinuses, may
require more radical surgical treatment. There is a high recur-
rence rate after needle aspiration or incision and drainage of
subareolar abscesses. Patay et al. first suggested excision of the
fistulous tracts and the major associated ducts as treatment for
recurrent subareolar abscesses [32]. The classic procedure, that
was later described by Hadfield, also involves radical excision
of the major subareolar ducts [33].
Retrospective case series suggest that excision of obstructed
ducts, which includes removal of chronically infected periareo-
lar tissue and fistulous tracts, may be required for definitive
treatment of recurrent subareolar abscess, and that this
approach may have a better success rate and lower recurrence
rate compared with incision and drainage or aspiration
alone [5,9,34–37]. For some patients, the infection may become so
problematic that a mastectomy is required [36].
Antibiotics
The incidence of antimicrobial-resistant pathogens causing soft
tissue infections has been rising, especially with S. aureus [38]. It
Expert Rev. Anti Infect. Ther. 12(7), (2014)

is well established that S. aureus is the most common patho-
genic organism cultured from breast abscesses [2,6]. Tradition-
ally, empiric therapy for patients with breast abscesses included
oral dicloxacillin or cephalexin for outpatient therapy or paren-
teral nafcillin/oxacillin for inpatients. The antibiotics are
directed toward S. aureus and Gram-positive bacteria with no
suspicion of methicillin resistance [39]. However, with the
increasing prevalence of methicillin-resistant S. aureus (MRSA)
in soft tissue infections, it has been suggested that empirical
antimicrobial therapy of breast abscesses should include cover-
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age for community-acquired MRSA.
There are no studies directly comparing the treatment of
breast abscesses with antibiotics alone to antibiotic therapy and
abscess drainage. All the current literature reporting on the
treatment of breast abscesses has utilized antibiotics concur-
rently with some type of abscess drainage procedure. In addi-
tion, a retrospective case series noted that for 40% of cases, the
infection resolved with surgical drainage, or with aspiration,
despite empiric utilization of antibiotics to which the isolated
pathogen was later found to be resistant [40]. However, there
are also no studies comparing abscess drainage alone to antibi-
otics and drainage in order to determine whether antibiotics
are actually necessary.
In the recent literature, community-acquired MRSA is com-
For personal use only.
monly associated with breast abscesses and has a prevalence
that ranges from 3.7 to 59% [38,41–43]. A variety of antibiotics
has been utilized to treat community-acquired MRSA, depend-
ing on local resistance patterns and patient factors such as a
history of intravenous drug use or diabetes. Oral antibiotics
that have been utilized for breast abscess treatment include clin-
damycin, trimethoprim–sulfamethoxazole, erythromycin and
cotrimoxazole. Paranteral antibiotics that have been utilized
include linezolid and vancomycin [40,41,43]. Observations from
retrospective case series, and current antimicrobial guidelines,
recommend clindamycin or trimethoprim–sulfamethoxazole as
the initial choice for empiric oral antimicrobial treatment for
breast abscesses and include MRSA coverage [39,41,43].
In addition to appropriate empiric antibiotic therapy, cultures
should be taken at the time of aspiration or drainage, and antimi-
crobial drug therapy should be modified to ensure adequate path-
ogen treatment based on culture and sensitivity testing.
Breastfeeding
Breastfeeding an infant from the breast that harbors the abscess
may put the infant at risk for developing pneumonia, lung
abscesses and death. These risks are especially a concern if the
breast abscess is caused by staphylococcal organisms [2,44]. For
breastfeeding women, the infant should not nurse from the
breast with the abscess but may continue nursing from the con-
tralateral, uninfected breast [2,44].
Expert commentary & recommendations
Our comprehensive literature review has revealed that there is a
lack of high-quality randomized trials that demonstrated the supe-
riority of one treatment plan over another, which leads to multiple
informahealthcare.com
Breast abscess Special Report
management options that are left to the discretion of the managing
physician. Lactational and nonlactational breast abscesses are two
distinct clinical entities, each with a discrete pathogenesis, though
their initial management is currently the same.
Needle aspiration may be carried out either with or without
ultrasound guidance and should be employed as first-line treat-
ment of breast abscesses. This approach has the potential bene-
fits of: superior cosmesis, shorter healing time and avoidance of
general anesthesia compared with surgical incision and drain-
age. However, multiple aspiration sessions may be required to
achieve cure (Strength of Recommendation: B).
Ultrasound-guided percutaneous catheter placement may be
considered as an alternative approach for treatment of larger
abscesses (>3 cm) (Strength of Recommendation: B). However,
this catheter must be left in the abscess cavity and cared for by
the patient with or without outpatient medical care. No spe-
cific number of aspiration sessions, or other specific standard-
ized criteria, has been defined to determine when percutaneous
drainage should be abandoned and surgical incision and drain-
age should be undertaken. Hospital admission or close outpa-
tient follow-up should be employed to ensure frequent
evaluation for any clinical signs of deterioration or nonresolu-
tion that may necessitate more emergent surgical procedures.
Surgical incision and drainage is required if needle aspiration
or catheter drainage is unsuccessful, and there is progression of
infection. Surgical incision and drainage should be considered
as first-line therapy for treatment of large (>5 cm), multilocu-
lated or long-standing abscesses (Strength of Recommendation:
B). Surgical incision and drainage of the abscess, or incision
and primary suture closure of the abscess cavity, are comparable
techniques for the surgical management of breast abscesses
(Strength of recommendation: C).
Recurrent subareolar abscesses may require surgical excision of
the major lactiferous ducts and mammary fistulas. Patients diag-
nosed with recurrent subareolar abscesses and fistulas should be
referred for consideration of surgical treatment (Strength of rec-
ommendation: C).
All breast abscesses should be treated with abscess drainage
and concurrent empiric antibiotic therapy. Antibiotic choice
may require modification during treatment and should be dic-
tated by culture and sensitivity testing of the specific infecting
organisms. Empiric antibiotics should be given in combination
with abscess drainage for the treatment of all breast abscesses.
Empiric therapy for breast abscess should include coverage of
community-acquired MRSA depending upon local resistance
patterns using clindamycin or trimethoprim–sulfamethixazole.
Cultures should be taken at the time of aspiration or drainage.
Subsequent antimicrobial drug therapy should be modified to
ensure adequate bacterial coverage based upon culture and sen-
sitivity testing (Strength of recommendation: C).
Five-year view
Management of breast abscesses has evolved from more invasive
surgical procedures to increasingly frequent utilization of
image-guided percutaneous techniques. Advances in imaging
759
 Special Report Lam, Chan & Wiseman

equipment and decreasing cost and greater access, even at
smaller institutions, have made image-guided drainage of breast
abscesses a safe and readily accessible procedure and provides
an alternative approach to abscess incision and drainage in the
operating room under general anesthetic. The ability to per-
form a greater number of these procedures at the bedside may
decrease the amount of time required to achieve infection
source control, which may be prolonged for surgical drainage
due to limited access to operating room resources.
As nonradiologist medical professionals, such as emergency
Expert Review of Anti-infective Therapy Downloaded from informahealthcare.com by UB der LMU Muenchen on 06/28/14
common, as well as the importance of prioritization of operating
room time, a management approach that includes percutaneous
options will help to limit impact on health care resources.
Regardless, surgical incision and drainage of breast abscesses will
remain an important backup treatment for patients who fail
nonsurgical management.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with
any organization or entity with a financial interest in or financial con-

room physicians and surgeons, become more facile with bedside
ultrasound, its increasing utilization in the clinic will mean that
patients will have a greater access to clinicians who are able to
carry out bedside abscess drainage with accuracy and in an expe-
dient manner. Furthermore, in the current environment where
concerns regarding wait times for operative procedures are
flict with the subject matter or materials discussed in the manuscript.
This includes employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or pending, or
royalties.
No writing assistance was utilized in the production of this
manuscript.

Key issues
• All breast abscesses should be treated with abscess drainage and concurrent empiric antibiotic therapy.
• Needle aspiration either with or without ultrasound guidance should be employed as first-line treatment of breast abscesses. However,
multiple aspiration sessions may be required.
• Ultrasound-guided percutaneous catheter placement may be considered as an alternative approach for drainage of larger (>3 cm)
abscesses.
For personal use only.

• Surgical incision and drainage is required if needle aspiration or catheter drainage is unsuccessful and there is progression of infection.
• Surgical incision and drainage should be considered for first-line therapy of large (>5 cm), multiloculated or long-standing breast
abscesses.
• Cultures should be obtained at the time of abscess drainage and antibiotic management tailored to the infecting organism’s
susceptibility profile.
• Empiric antibiotics targeting methicillin-resistant S. aureus may be required for patients who are known to be colonized or considered to
be at high risk.
• For breastfeeding women, the infant should not nurse from the breast with the abscess but may continue nursing from the contralateral,
uninfected breast.
• Future research should prospectively evaluate the utilization of aspiration or percutaneous catheter drainage techniques in terms of
frequency of progression of infection requiring surgical management in order to limit selection biases. The optimal frequency of aspira-
tions, time interval between aspirations and duration of catheter placement also requires further study.

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