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

  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: