European Journal of Cardiovascular Medicine

Lactational infections of the breast arise from entry of bacteria through the nipple into the duct system.¹ The intermediary is usually the infant as 50% of infants harbour S. aureus in the nasopharynx.² Breast abscesses in the postpartum period usually occur within the first few weeks of breast feeding and present with point tenderness, erythema and hyperthermia.³ Presence of pus can be confirmed by needle aspiration.² Preoperative ultrasonography helps to delineate the extent of drainage required.³

It used to be recommended that all breast abscesses have to be incised and drained.² This can lead to prolonged healing time, difficulties in breastfeeding, and unsatisfactory cosmetic outcome.³ Hence, conventional incision and drainage has been replaced by less invasive procedure of repeated needle aspirations under antibiotic cover² and the former is reserved for those cases in which repeated needle aspiration has failed or there is other indication, such as, thinning and necrosis of overlying skin.³

However, drainage of breast abscesses by ultrasound guided needle aspiration mandates the availability of an interventional radiology department.⁴ Percutaneous placement of suction drain in treatment of breast abscess is an alternative method of drainage of breast abscess. It is scarless and preserves function of breast feeding. ⁴ Present study was aimed to study etiology, clinical features and surgical management of breast abscess at a tertiary hospital.

Present study was single-center, prospective, observational study, conducted in department of general surgery, at K R Hospital Mysuru, attached to Mysore Medical college and Research Institute, Mysuru, India. Study duration was of 18 months (January 2020 to June 2021). Study approval was obtained from institutional ethical committee.

Inclusion criteria

• Female patients with age more than 18 years, with diagnosis of breast abscess confirmed by clinical or radiological method, willing to participate in present study

Exclusion criteria

• Female patients less than 18 years of age.
• Patients who were not willing for surgical intervention
• Patients with other benign breast diseases.

Study was explained to patients in local language & written consent was taken for participation & study. Based on detailed history, thorough clinical examination and needle aspiration, the diagnosis of breast abscess was made. These patients were subjected to the required preoperative investigations. Investigations such as Blood grouping and Rh typing, complete blood count (included hemoglobin concentration, total leucocyte count, differential leucocyte count, erythrocyte sedimentation rate), bleeding time and clotting time, random blood sugar, blood urea and serum creatinine, urine routine, HIV, HBsAg, ECG, USG breast, pus culture and sensitivity were done in all patients.

Patients underwent various modes of treatment. Antibiotic with amoxycillin and clavulanate combination 625 mg was given 8th hourly for 2 days empirically, following which antibiotic was changed according to the culture and sensitivity report. Injection paracetamol was given intravenously 8th hourly for the first 2 days following which oral paracetamol was given.

OPERATIVE PROCEDURES

1. Incision And Drainage (I & D)- A linear incision is made over the most fluctuant and dependent part of the abscess. All the loculi are broken by finger dissection. The pus is drained and the cavity is irrigated with hydrogen peroxide and povidone iodine. The cavity is then loosely packed with betadine-soaked gauze.
2. Percutaneous Needle aspiration (PCNA) - An 18 G needle and a 20 ml syringe were used in each case. The breast was stabilized with index finger and thumb. The abscess was localized and needle was inserted after giving local anaesthesia. The abscess was aspirated, syringe was detached and pus was sent for culture and sensitivity. Another syringe of same size was again attached to the needle and pus was aspirated. The procedure is carried out until no pus was aspirated. Aspiration was repeated every alternative day if required until the mass completely resolved or until three needle aspirations performed. If the abscess cavity had not resolved by this time, this result was accepted as a treatment failure.
3. Percutaneous placement of Suction Drain (PCSD) - 18F perforated catheter with the curved needle was introduced from one side of the abscess and then brought out through the opposite side of the abscess and the perforated end of the catheter was left in the abscess cavity. The entry site was closed with silk. Hydrogen peroxide and povidone iodine wash was given through the catheter which was fixed at the exit wound and then connected to the suction apparatus. The catheter was irrigated daily with hydrogen peroxide and povidone iodine and was removed between 3 and 5 days or when discharge is less than 10ml.

An ultrasound scan of the operated breast was done on the 3rd and 7th day to rule out residual abscess. Each patient was analysed with reference to post operative pain (based on visual analog scale), residual abscess (based on USG), time required for complete healing. Each patient was followed up in outpatient department at 1 week, 2 weeks, 4 weeks and 8 weeks after discharge.

Data was collected and compiled using Microsoft Excel, analysed using SPSS 23.0 version. Frequency, percentage, means and standard deviations (SD) was calculated for the continuous variables, while ratios and proportions were calculated for the categorical variables. Statistical analysis was done using descriptive statistics.

In the present study most commonly affected age group was 25-30 years, with 30 cases (73.3%) >25 years, with 10 cases less than 25 years (26.6%). The youngest patient in my study was19 years and the oldest is33 years.

Table 1: Age-Wise Distribution

In the present study 12 patients had breast abscesses of size less than 4cm and 16patients had breast abscess of size 4-5cm and 12 patients had breast abscesses of size greater than 5 cm.

Table 2: Size of abscess

In this present study VAS grade for the group that underwent percutaneous placement of suction drain group was G2 for 8 patients (80%) and G3 for 2 patients (20%). VAS grade for the group that underwent incision and drainage was G4 for 7 patients (46.6%) and G5 for 8 patients (53.3%). VAS grade for PCSA was G1 for 8 patients (53.3%) and G2 for 7 patients (46.6%).

Table 3: Postoperative pain

Chi-square=55.11, P<0.000, HS

In the present study the mean duration of complete healing in patients who underwent incision and drainage was 21.6 + 6.8 days and patients who underwent percutaneous placement of suction drain was 18.5 + 5.7 days and for PCNA 17.8±4.4 days.

Table 4: Duration of complete healing (days)

A sample of pus was sent for culture and sensitivity in each patient. The result was reported as Staphylococcus aureus for 27 patients, Pseudomonas in 7 patients, Proteus species in 4 patients and no growth was seen in 2 patients. Most of the organisms were sensitive to ampicillin, amoxycillin cefotaxime and linezolid.

In this study, S. aureus was the causative organism in 10 cases of I&D,11 cases of PCNA and 6 cases of PCND. Pseudomonas was the organism in 2 cases of I&D, 3 cases of PCNA and 2cases of PCND. Proteus was the organism in 2 cases of I&D, 1 case of PCNA and 1 case of PCND.There was no growth in 3 cases.

Table 5: Causative organism

In our study 4 patients had recurrence of breast abscess.1 patient (6%) among I&D group,2 patients (13.3%) among PCNA group and No growth one patient (10%) among PCSD group.

Table 6: Recurrence

In our study patients who underwent PCNA had no scars. Patients among I &D groups 2 of them had scar of size 3 to 5 cm and 13 had scar size more than 5 cm. Patients among PCSD group 2 of them had scar of size1 to 3 cm and 8 had scar size between 3 to 5 cm.

Table 7: Size of the scar

The incidence of mastitis in lactating women is 2% to 3%.⁵ The WHO review of mastitis (2000) concluded that 11% of women with mastitis develop breast abscess in the puerperal period from a study conducted by Devereux WP et al.,.⁶ Amir et al.,⁷ conducted a study of 1183 women, out of which 0.4% (5/1183) developed breast abscess. Marshall et al.,⁸ estimated the rate of breast abscess in women with mastitis as 4.6 % (3/65).

Majority of the breast abscesses are lactational. Efem et al.,⁹ in his study of 299 breast abscess patients observed that majority of the patients had lactational breast abscess similar to the present study. Breast abscesses are most common in women of childbearing age, with a mean age of 26.6 years. Non-lactating breast abscesses have a wider range, with a peak incidence in the fourth decade of life.⁵ In a study conducted by Tewari et al. on 30 patients with lactational breast abscesses, the age of incidence ranged between 18 and 34 years.⁴

In a study conducted by Faisal et al. on 30 patients on aspiration of breast abscesses under ultrasound guidance, the mean age of incidence was 31.93 years. A study conducted by Aslam et al. on benign breast diseases concluded that the mean age of incidence of breast abscess is 30.77 ± 8.77 years.

Chuwa et al.,¹⁰ conducted a study on MRSA abscesses in postpartum women and observed that the median age of incidence was 31.5 years.²⁵ Another study conducted by Kastrup et al.,¹¹ on acute puerperal breast abscesses concluded that the mean age of incidence was 29 years, ranging from 21-39 years. A study by Dener et al.,¹² on breast abscesses in lactating women showed that the mean age of incidence of breast abscess was 26 years. In the present study, the mean age of incidence of breast abscess was found to be 26.65 years (range- 19 to 33 years).

In the present study, the average size of the abscess was 4.8cm ranging from 2cm to 10cm. In the study conducted by Chuwa et al.,¹⁰ the average size of the abscess was 4.3cm ranging from 2 to 10 cm. A study conducted by Kastrup et al.,¹¹ on 19 patients with lactational breast abscesses showed an average abscess diameter of 5.9 cm, ranging from 3 to 14 cm. Both lactational and non-lactational breast abscesses were included in a study conducted by Dahiphale et al.,¹³ and showed an average abscess size of 3.5cm. Similar results were observed by Christensen et al.,¹⁴ (3.5cm) and Chandrika et al.,¹⁴ (3.49cm).

In the present study the mean duration of complete healing was 18.5 days for the group that underwent percutaneous placement of suction drain and was 21.2 days for the group that underwent incision and drainage and 17.8 for the group that underwent needle aspiration. In the study conducted by Chuwa et al.,¹⁰ the mean time for complete healing in patients who underwent incision and drainage of breast abscess was 21 days (range, 5–28 days). Mean time taken for complete healing in patients who underwent incision and drainage of breast abscesses in a study conducted by Karvande et al.,¹⁶ was 7.7 days.

We noted that percutaneous suction drain had some advantages such as in multiloculated abscesses, the loculi are punctured by the trocar of the suction drain that traverses the entire length of abscess. The negative suction drain collapses the abscess cavity and drains any remnant pus. Patients can continue breast feeding immediately after the procedure. There is minimal scarring and distortion of the breast tissue. The discomfort associated with carrying the suction drain is minimal and post catheter placement care is simple and can be made easier by the assistance of a general practitioner or a community nurse. Percutaneous placement of suction drain is cost effective. It has superior cosmetic outcome. While disadvantages were, it needs general anaesthesia & it cannot be practiced in rural areas where suction drains are not easily available.

Percutaneous needle aspiration does not need costly equipments, can be done under local anaesthesia, as outpatient basis, better cosmetic appearance & less post operative pain. But percutaneous needle aspiration is not useful for large breast abscess & needs repeated ultrasonography to look for residual abscess which will be difficult in rural areas.

Advantages of incision and drainage were less recurrence rate, do not require costly equipments & suitable for practicing in rural areas. Disadvantages of incision and drainage were poor cosmetic outcome, more post operative pain & longer time to heal.