Breast abscess is a common cause of morbidity in women. It is defined as a “collection of pus within the breast tissue, surrounded by a pyogenic membrane.”1,2 It is less common in developed countries because of nutrition and good standards of living, improved maternal hygiene and early administration of antibiotics.3,4, Nowadays, breast cancer ranks first in the majority of countries and is responsible for 1 in 4 cancer diagnoses and 1 in 6 cancer deaths.5 In 5%–11% of cases, it develops as a complication of mastitis⁶,⁷ in breastfeeding women,⁸ and is termed a puerperal or lactational abscess. Other breast abscesses that are not associated with breast feeding are known as non-puerperal breast abscesses.9 The most common pathogen in breast abscess is Staphylococcus aureus.10 Other microorganisms are Staphylococcus epidermidis, Streptococcus pyogenes, and anaerobes such as Peptostreptococcus and Bacteroides.11 A sterile culture is reported in 21%–45% of cultures.12-14 Breast infections secondary to tuberculosis and other mycobacteria, fungi, or parasites can  also occur but are less common.9 The traditional treatment is by surgical incision,15 digital disruption of septa, evacuation of contents with occasional placement of surgical drains and administration of systemic antibiotics. This procedure requires general anesthesia, prolonged healing time, regular dressing, difficulty in breast feeding and possible unsatisfactory cosmetic outcome.12,16 Recurrence can be seen in approximately 10–38% of abscesses which requires additional surgical drainage.12           Ultrasound is an excellent imaging technique for diagnosing and evaluating the extent, site, size and internal characteristics of breast abscesses17 and guiding needle placement during aspiration and also enables visualization of multiple abscess loculation.18 This procedure is less expensive19, 20 and is associated with less recurrence and excellent cosmetic results21. Needle aspiration under ultrasound guidance is an effective treatment for breast abscess irrespective of abscess volume and size. The cost affectivity of ultrasound guided aspiration is much better than that of Incision and Drainage13

Study Design and Setting

This was a prospective study conducted between 1st December 2012 and 31st May 2014 in the department of General Surgery at Christian Medical College and Hospital, Ludhiana. The study was approved by the Institutional Ethics Committee.

Study subjects

INCLUSION CRITERIA: Female patients aged 18 years and above presenting with a diagnosis of breast abscess were included in the study.

EXCLUSION CRITERIA: Patients with

1. a) failed breast abscess aspiration
2. b) chronic breast abscesses
3. c) overlying necrotic skin
4. d) abscess already draining

Patients who met the inclusion criteria were enrolled into the study. Diagnosis was based on the presence of one or more of the following:-

• Breast pain
• Fever
• Fluctuant tender breast swelling
• Induration

The diagnosis was confirmed sonographically by the presence of one or more of following signs-

• Collection with echogenic material or moving debris
• Hyperechogenic zone at the periphery of collection
• Thin hyperechogenicity at the collection borders
• Posterior acoustic enhancement
• Thin echogenic septa
• Areas of decreased parenchymal echogenicity or increased fat echogenicity
• Skin thickening
• Increased peripheral vascularity on color Doppler images

The size of each abscess was estimated using ultrasound imaging. All patients received a pre-procedural dose of amoxicillin–clavulanate. Written informed consent was obtained from all participants. Skin preparation was carried out using povidone-iodine solution. Under aseptic conditions, local anesthesia was administered by infiltrating 2% lignocaine with a 24-gauge needle at a site adjacent to the abscess. Ultrasound-guided aspiration was then performed using a 16-gauge needle attached to a 20 ml syringe. The initial aspirate was sent for microbiological culture and antibiotic sensitivity testing. Aspiration was continued until no significant residual pus remained. Following the procedure, patients were prescribed oral amoxicillin–clavulanate 625 mg three times daily for a duration of seven days. Antibiotic regimens were adjusted based on clinical response and culture sensitivity results.

Patients were followed up at 48 hours, one week, two weeks, and one month after the final aspiration. At each follow-up visit, patients were assessed clinically for resolution of symptoms and signs. If any symptoms persisted, a repeat ultrasound was performed to evaluate for residual or recurrent abscess, and further management was planned accordingly. In this study, healing was defined as complete resolution of the breast abscess. Resolution was confirmed both clinically—by the absence of breast tenderness, swelling, or a residual wound at the site of the previous abscess—and sonographically—by the complete absence of fluid collection. Treatment failure was defined as the absence of complete resolution after five aspiration attempts, in which case incision and drainage (I&D) was performed. In patients over 35 years of age with a palpable breast lump, mammography along with fine-needle aspiration cytology (FNAC) or trucut biopsy was conducted to exclude any underlying malignancy.

1. Distribution according to breast feeding: Considering the breast feeding, it was noted that approximately 61% patients were lactating and 39% were non- lactating. This is shown in Table 1

Table 1: Distribution of Patients According To Breast Feeding

2.Distribution of size according to Breast Abscess: One patient had smallest breast abscess with largest dimension of 2 cm. Approximately 53% patients had small breast abscess with largest dimension between 2 to 4 cm and 22% patients had breast abscess largest dimensions of 4.1 to 6 cm. Another 22% patients were in group of breast abscesses with largest dimensions of 6.1 to 8 cm. This is shown in Table 2.

Table 2: Distribution of Patients According to the Size of Breast Abscesses in Largest Dimension

3. Distribution according to pus culture sensitivity: On pus culture sensitivity, 35 (97.22%) patients had Methicillin Sensitive Staphylococcus aureus and 1 (2.78%) patient had Mycobacterium tuberculosis in the pus culture sensitivity. In 30 (83.33%) patients tablet Amoxicillin Clavunate 625 mg three times a day (TDS) was given for maximum up to 10 days. In 5 patients (13.89%) patients, there was no relief with tablet Amoxicillin clavunate 625 mg TDS. They were started on Tablet Linezolid 600 mg twice a day (BD) and only one patient who was having Mycobacterium tuberculosis in pus culture report was started on Anti Tubercular Therapy. This is shown in Figure 1 and Table 3.

Table 3: Distribution of Patients According To Antibiotics Used

4. Follow up- This table shows follow-up of patients after 48 hours, 1 week, 2 weeks and after 1 month. This is shown in table 4.

Table 4: Follow Up of Patients

5. Distribution according to number of aspirations: Approximately 66.67% patients had complete resolution of symptoms after one aspiration only. In our study, 19.44% patients needed 2 aspirations and 2.78% had undergone 4 aspirations for complete resolution. Approximately 4 (11.11%) patients underwent incision and drainage of abscess.

Table 5: Distribution of Patients According to Number of Aspirations Required For Complete Resolution

Lactational breast abscesses are more common than non‑lactational breast abscesses. In our study of 36 cases, 22 (61.11%) cases were lactational and 14 (38.89%) cases were non‑lactational breast abscesses which is comparable with the findings in the series.22 with 83% (lactational) and 17% (non‑lactational). However, another study17 reported 53.3% of non‑lactational and 46.7% of lactational in his study. In our study, the mean age of patients was 29.68 years (range: 18‑55 years) which is slightly different with the finding of these studies.17,23,24 with the mean age of 31.93 years and 32 years.

In our study 53% patients had left side affected and 47% had right side affected. In this study.17, 53.33% patients and in this study.23 48.21% had left side breast abscess. The average length of symptoms in our study was 6.14 days while in this study17 the average length of symptoms was 11.63 days. In terms of chief complaints, all patients had symptoms of pain, 97.22% had palpable mass and redness of the overlying skin and 69.44% had fever. However, in this study patients reported having pain in 83.3%, palpable mass in 60% of patients, erythema of the overlying skin was seen in 33.33% and fever in 46.7% patients.17

In this study, the median pus volume at the initial aspiration was 35.36 ml (range 5 to 170 ml). However, in this study17 the median pus volume was 14 ml (range, 1-200 ml) and in this study12 the median pus volume was 28 ml (range, 1-225 ml). Staphylococcus aureus was the most common pathogen isolated in our study in 35 (97.22%) cases. However, in these studies17,23,24, Staphylococcus aureus was seen in 76.7%, 89% and 64% of the total patients respectively. Of the 36 patients aspirated in our study, 24 (66.67%) resolved well with single aspiration and antibiotics, 7 (19.44%) patients required 2 aspirations and one patient required 4 aspirations for resolution. Four (11.11%) cases failed to repeated aspirations and underwent incision and drainage. In another study,12 67 patients who completed treatment, 38 patients (57%) obtained complete resolution of the abscess with one aspiration, 18 patients (27%) with two aspirations, and eight patients (12%) with more than two aspirations.

The success rate by needle aspiration without resorting to surgical drainage was 88.89%. This study 25 reported a success rate of 85%. Another study22 had a success rate of 82%, while this study17 reported a success in 83.3% of patients. This study12 reported a success rate of 90%. In our study the size of the breast abscess ranged between 2 cm to 8 cm in largest dimensions. However, in this study,26 the size of the breast abscess ranged from 0.8 to 7 cm. This study23 treated abscesses less than 3 cm by using needle aspiration and abscesses more than 3 cm and larger by using catheter drainage like previous reports of this study.8 Nonetheless, their study does not substantiate 3 cm as being the ideal cutoff point between needle aspiration and catheter drainage. It may not be necessary to place a catheter in all patients who have abscesses that are 3 cm and larger.

In our study, catheter placement was not employed in any patient; instead, serial ultrasound-guided aspirations were performed until clinical improvement was achieved. In our study, failure of aspiration was not related to size of the abscess. We were able to treat abscesses as large as approximately 7 cm with aspiration. The patients in which aspiration method failed had abscesses which were multiloculated. Infact in some patients, abscess with large size and long duration of illness but uniloculated were treated with ultrasound guided drainage successfully. The abscesses were multiloculated in 4 (11.11%) patients in our study while in this study17, 9 (30%) abscesses were multiloculated. Another recent study21 stated that neither size nor location showed any independent effect on the recovery. Our results are in accordance with their study.

In our study, all patients were followed up at 48 hours of the first aspiration. The patients in whom symptoms were not resolving, review ultrasound scan was done and were taken up for aspiration or incision and drainage depending upon scan. Those who had resolved symptoms were followed up after 1 week, 2 weeks and 1 month of the last aspiration. One patient who was symptomatic after 2 aspirations underwent 2 more subsequent aspirations at 48 hours interval.  She was also followed after 1 week, 2 weeks and 1 month of the last aspiration. 32 patients who underwent needle aspiration have acceptable cosmesis. Similar outcomes of good cosmesis after needle aspiration of breast abscess were reported in these studies.17,22,27,8 In our study no recurrence of breast abscess was seen during follow up. This result was also seen in another study.16 There were few limitations to our study. We excluded patients with co-morbid disease because the underlying pathological process itself can be responsible for recurrences and could have affected the results.

Ultrasound-guided needle aspiration is a safe, effective, and minimally invasive method for managing both lactational and non-lactational breast abscesses. In our study, a high success rate (88.89%) was achieved without the need for surgical drainage, even in abscesses larger than 3 cm. Most patients responded well to a single aspiration, with excellent cosmetic outcomes and no recurrences observed during follow-up. These findings support ultrasound-guided aspiration as a reliable first-line treatment for breast abscesses, minimizing morbidity and preserving breast function.

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