Mastitis/ breast abscess Flashcards
What is mastitis?
Mastitis is defined as inflammation of the breast with or without infection
Mastitis with infection can be lactational (puerperal) or non-lactational (e.g. duct ectasia)
mastitis can lead to abscess formation
What is a breast abscess?
a localised area of infection with a walled-off collection of pus → main complication of mastitis, but it may or may not be associated with mastitis
What are some risk factors for mastitis?
(Mastitis typically develops when milk is not properly removed)
RFs:
- BREAST FEEDING
- poor latch
- cracked nipples
- use of a breast pump
- weaning
- tight fitting clothes
- trauma
- post nipple piercing
- smoking; can cause damage to the breast tissue
What are the causative agents of breast abscesses?
⇒ Lactational: staphylococcus aureus
⇒ Non-lactational: staphylococcus aureus or anaerobes
most common:
- staph aureus
- coagulase-negative staphylococci.
- Methicillin-resistant S aureusis (MRSA)
Breast infections may sometimes be polymicrobial (up to 40% of abscesses), with isolation of aerobes as well as anaerobes
What are some risk factors for breast abscess?
- lactation
- smoking
- diabetes (immunosupression)
- inflammatory breast cancer
- mammary duct ectasia
- periductal mastitis
- wound infections e.g. from surgery
Summarise the epidemiology of mastitis
● Mastitis common in breast feeding women – 10%
● Lactational breast abscesses common
● Non-lactational tend to occur in 30-60 yr smokers
What are some causes of non-infectious mastitis?
- idiopathic granulomatous (lobular) inflammation- benign disease of unknown aetiology
- underlying duct ectasia (peri-ductal mastitis or plasma cell mastitis)
- other inflammatory conditions (e.g., foreign body reaction: nipple piercing, breast implant, or silicone)
What are some causes of lactational mastitis?
- Bacteria entering through breaks in the nipple
- Prolonged milk stasis, leading to engorgement of the ducts
What are some causes of non- lactational/ non-puerperal mastitis?
- idiopathic
- related to malignancy
- infection (surgery, piercings)
What signs of breast abscess/ mastitis can be found on history?
- fever
- decreased milk outflow
- breast warmth
- purluent discharge from nipple or lesion
- breast tenderness
- breast firmness
- breast swelling
- breast erythema
- flu-like symptoms, malaise, and myalgia
- breast pain
- RFs: smoking, diabetes, breast feeding
What signs of mastitis can be found on examination?
- Red, swollen, tender breast
- increased warmth of affected area
- erythema, possible edema
- fluctuant, palpable mass
- distant skin infections
- Cracked nipple
- Non-lactational abscess: scars or tissue distortion from previous episodes; signs of duct ectasia
- Systemic:
1. pyrexia of >38°C (100.4°F)
2. tachycardia
What investigations are used to monitor possible mastitis?
- Diagnosis usually based on presentation
- Breast examination
- breast ultrasound (helps differentiate b/t tumor vs abscess)
- diagnostic needle aspiration drainage
- cytology of nipple discharge or sample from fine-needle aspiration
- milk, aspirate, discharge, or biopsy tissue for culture and sensitivity
- histopathological examination of biopsy tissue
What is the first line approach to managing a patient with breast abscess?
- ABCDE assessment
What is the next step if a pt with a breast abscess is found to be unstable after the ABCDE assessment?
- stabilize airway, make sure they are breathing
- Address circulation by obtaining IV access (initiating IV fluids for resuscitation)
note: rare for breast abscess to be sole reason for haemodynamic instability- check for sepsis
What is the next step if a pt with a breast abscess is found to be stable after the ABCDE assessment?
- Take a focused history and perform a breast examination
- on history look for signs and risk factors
What is the first line of management for breast abscess if there are no systemic signs or severe symptoms?
effective milk removal and supportive care: continue breastfeeding, if not all milk removed, use hand or breast pump to remove
- avoid bras
What is the first line of medical management for breast abscess if there are systemic signs or severe symptoms?
a) Empiric antibiotic therapy:
1. panicillinase- resistant penicillins:
- “Dicloxacillin”
2. Beta- lactam hypersensitivity/ MRSA:
“Clindamycin”
b) +/- pain management:
acetaminophen or ibuprofen
What is the second line of medical management for breast abscess after ABs and pain management?
Ultrasound to determine the size of the abscess
How does management differ depending on the size found on US of the breast abscess?
< 5 cm:
- ultrasound- guided needle aspiration
- repeat for 2-3 days until no fluid is visible on US
- send for culture and sensitivity
> 5 cm: surgical incision + drainage
What are the next steps of management for breast abscess if the pt has an adequate response to the antibiotics and pain killers?
Complete the AB course for 10-14 days
What are the next steps of management for breast abscess if the pt has an inadequate response to the antibiotics and pain killers?
assess skin appearance for ischaemia/ necrosis
What are the next steps of management for breast abscess if the pt has signs of ischaemia/ necrosis on skin assessment
- surgical incision + drainage
- deberidement of necrotic tissue
- assess for inflammatory breast cancer
What are the next steps of management for breast abscess if the pt shows no signs of ischaemia/ necrosis on skin assessment
- US guided needle aspiration
- Surgical incision + drainage of abscess
- assess for inflammatory breast cancer
What are possible complications for mastitis/ breast abscesses and its management?
● Sepsis
● Recurrent mastitis
● Abscess is complication of mastitis
Summarise the prognosis for patients with mastitis/breast abscesses
Good:
When treated promptly and appropriately, most breast infections, including abscess, will resolve without serious complications. Resolution of mastitis after 2-3 days of appropriate antibiotic therapy is expected among most patients.
Lactational abscesses tend to be easier to treat than non-lactational abscesses because their aetiology and pathology is better understood. Non-lactational abscesses can be multifactorial and have a greater risk of becoming chronic.
describe the pathophysiology of mastitis
In lactational mastitis, milk stasis or milk overproduction, coupled with infection from bacteria entering the breast via a traumatised nipple (e.g., cracked or fissured) and/or from the infant’s mouth, can lead to mastitis. Transient breast enlargement from maternal hormones in neonates makes them vulnerable to mastitis.
