Breast Surgery

Mastitis and Breast Abscess

Mastitis is breast inflammation on a spectrum from lactational inflammation to bacterial infection; a breast abscess is a drainable collection that needs urgent ultrasound assessment and drainage, while persistent or non-lactational inflammation needs a clear malignancy safety-net.

In a nutshell

Mastitis is breast inflammation, usually lactational, but it is not automatically bacterial. Continue responsive breastfeeding when possible, avoid over-emptying or firm massage, use cold measures and analgesia, and review quickly if not improving. Treat likely bacterial infection using current NICE CKS and BNF/local-formulary advice. A suspected abscess needs urgent ultrasound and drainage. Non-lactational, recurrent or persistent disease needs breast-team assessment to exclude malignancy.

Classic presentation

A breastfeeding patient develops rapid unilateral breast pain, warmth, swelling and a tender wedge or hard area, with or without fever and flu-like symptoms. A persistent focal lump suggests an abscess.

Key points

Mastitis is an inflammatory spectrum; a hot, red breast does not by itself prove bacterial infection.
Continue breastfeeding responsively if possible; hand express only enough for feeding or comfort and avoid unnecessary extra pumping.
Use cold compresses, rest and suitable analgesia; avoid firm massage and tight clothing.
Review if symptoms are not improving within 12 to 24 hours of appropriate home care or within 48 hours of antibiotics.
Use current NICE CKS and BNF/local-formulary advice for antibiotic choice, dose, duration and breastfeeding safety.
A suspected abscess needs urgent ultrasound and drainage; aspiration may need to be repeated.
Continue breastfeeding during abscess treatment when possible; it does not usually harm the baby.
Non-lactational, recurrent or persistent inflammation needs breast assessment, not indefinite repeat antibiotics.

First-line investigation

Clinical assessment, with urgent breast ultrasound for a suspected abscess, persistent focal lump or unexpectedly poor response.

Management

Triage severity and abscess risk

Escalate urgently for sepsis, severe cellulitis, skin compromise, an obvious abscess, implant-associated infection or significant deterioration; otherwise assess breastfeeding status, focal mass and systemic symptoms.^7,5,1

Support inflammation and protect feeding

Continue responsive breastfeeding when possible, hand express only enough for feeding or comfort, check attachment, use cold compresses and suitable analgesia, and avoid firm massage, tight clothing and unnecessary extra expression.^2,3,4
If bacterial infection is likely or symptoms fail to improve with supportive care, use the current NICE CKS and BNF/local formulary for antimicrobial choice, dosing, duration and allergy or breastfeeding checks.^1,4,2

Review response promptly

Arrange review if symptoms are not better within 12 to 24 hours of appropriate home care or within 48 hours of antibiotics; involve breastfeeding support when recurrent feeding or attachment problems are contributing.^2,3,1

Drain a confirmed abscess

Arrange urgent ultrasound and drainage of a confirmed collection; aspiration may need repeating, while incision and drainage is used when aspiration is unsuitable or unsuccessful or the skin is compromised. Send pus for culture and continue breastfeeding when possible.^5,1

Safety-net atypical and recurrent disease

Refer persistent, recurrent or non-lactational inflammation, a residual mass, peau d'orange, suspicious nipple or skin change, sinus or fistula for breast assessment and appropriate imaging or tissue diagnosis; do not rely on repeated empiric antibiotics alone.^6,1,2

Exam traps

Mastitis is not always bacterial, so do not prescribe antibiotics for every red breast without assessing the clinical course.
Do not advise aggressive breast massage or pumping to empty the breast.
Do not treat a confirmed abscess with antibiotics alone; arrange drainage and send aspirate for culture.
Breastfeeding can usually continue during mastitis and abscess treatment.
Persistent, recurrent or non-lactational mastitis needs breast assessment to exclude inflammatory breast cancer or another lesion.

Illustrations

Lactational mastitisA clinical photograph of a wedge-shaped area of erythema and swelling on a lactating breast, with a caption explaining that the clinical appearance does not by itself distinguish inflammation from bacterial infection.XXXANONXXX3245, Wikimedia Commons · CC-BY-SA-4.0

Breast abscess on ultrasoundA breast ultrasound showing a well-defined fluid collection with internal echoes, annotated as a collection requiring specialist drainage rather than antibiotics alone.Nevit Dilmen (talk), Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.