Mastitis and breast abscess (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Highland HSCP
  • Primary and Secondary Care
  • Adults only

Pathway

Initial assessment of patient

Are any of the below present?

  • Signs of sepsis

  • Threatened or actual skin necrosis

  • Spreading cellulitis

  • Diabetes

  • Immunosuppression

⇓

YES: Admission to Surgical Assessment

NO: Outpatient management

  • Refer to on call General Surgery Consultant (x 1302) OR Registrar (#1301)

  • If recent breast surgery, contact operating Consultant

  • Oral antibiotics (see below)

  • Send OP IUR to Highland Breast Unit if persists after 7 days treatment or concerned about malignancy

  • Needle aspiration of superficial abscesses in primary care if experienced and confident to do so

Surgical assessment examination findings

  • If concerned about potential malignancy, refer to outpatient breast clinic for triple assessment.

  • If breast pain only (no systemic signs or symptoms) give analgesia and refer back to GP

Red, hot, painful breast ONLY

Red, hot, painful breast with ABSCESS +/- skin necrosis

Lactational Mastitis

Management:

  • Advise mother to KEEP FEEDING or expressing on the affected side as this is most effective drainage. See Mastitis, Prevention and Treatment Policy

  • If baby unable to attach to affected breast, encourage
    expressing of the breast at least 8 times in 24 hours

  • Consider a warm or cool compress for symptomatic
    relief but ensure not too hot

  • Consider antibiotics if symptoms persist or worsen after
    12 to 24 hrs (see below)

Non-lactational
mastitis

Management:

  • Antibiotics as per guidelines
    (see below)

  • Add anaerobic cover if smoker

  • Consider a warm or cool compress for symptomatic
    relief, but ensure not too hot

Breast Abscess

Management:

  • Is there an obvious drainable collection?
    Percutaneous drainage with 21G needle or above

  • Use image guidance if implant present

  • Send aspirate for culture and sensitivity

  • Antibiotics as per guidelines (see below)

  • Is there skin necrosis present?
    Consider I&D with skin debridement under GA.

Recurrent abscesses or necrotic lesions may be related to PVL producing Staph aureus, including MRSA. Seek advice from Microbiology

⇓

Antibiotic therapy

If systemically unwell give IV, otherwise give orally.

Note, oral route preferred for metronidazole if able to take oral medication, IV only required if nil by mouth (e.g. obstruction) or severe sepsis. Note 'sip til send' policy allows oral medication with water up until time of surgery.

 

Antibiotic

IV

Oral

Duration

First line

Flucloxacillin

1 to 2g, 4 times daily

500mg, 4 times daily

Abscess: 7 to 10 days

Mastitis: 10 to 14 days

Recurrent abscess or smoker

Add metronidazole

500mg, 3 times daily

400mg, 3 times daily

Penicillin allergy (covers anerobes)

Clindamycin

600mg, 4 times daily

300mg, 4 times daily

Notes:

⇓

Re-assess 

Is there clinical improvement?

YES: Plan for home

NO

  • Consider step down from IV to oral, if clinically well

  • Outpatient appointment with Breast Surgeons if
    concerned about underlying malignancy

  • Request USS Breast for assessment of deeper collection. Discuss with Breast Surgeon or Breast Radiologist

  • Discuss current antibiotic therapy with Microbiology

ABBREVIATIONS

Abbreviation Meaning
IUR Inter-unit referral
I&D Incision and drainage
IV Intravenous
GA General anaesthetic
MRSA Methicillin-resistant Staphylococcus aureus 
OP Outpatient
PO Oral
PVL Panton–Valentine leukocidin 
USS Ultrasound
21G 21 gauge

Editorial Information

Last reviewed: 27/06/2024

Next review date: 30/06/2027

Author(s): Cancer Services Directorate.

Version: 2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Mr I Daltrey, Consultant Breast Surgeon, B Tanner, J Pollard.

Document Id: TAM456

Related resources

Further information for Health Care Professionals: