Background
If clinical examination should lead to the suspected diagnosis of a breast abscess or mastitis (can be lactational or non lactational, and infective or non infective), please follow this protocol:
- Arrange (same day) ultrasound to confirm diagnosis ± guided needle aspiration (rather than incision) [Bestbets]
- If ultrasound examination confirms an abscess (or it is impossible to arrange), apply local anaesthetic cream to the most fluctuant area of skin and leave for one hour
- Aspirate the area with a large bore needle (or grey venflon) and send pus for microbiology
- Whether pus is obtained or not, prescribe a seven day course of Co-amoxiclav (625mg q8h) or Flucloxacillin (500mg q6h) to all patients unless allergic to Penicillin (Erythromycin (500mg PO q8h) is then a suitable alternative but beware if on Warfarin
- Prescribe an oral antibiotic if the woman has a nipple fissure that is infected, symptoms have not improved (or are worsening) after 12–24 hours despite effective milk removal, and/or breast milk culture is positive
- Most patients will not need to be admitted unless toxic, conservative treatment has failed or the abscess needs to be incised and drained because of imminent discharge through the skin
- Advise simple analgesia and an NSAID, and the following as per type of Mastitis
Lactational Mastitis
- Advise that it is safe to continue - all the advised antibiotics and analgesics are safe, and milk with pus or blood in it will not harm their child. Emptying the breast and clearing any blockage is key to swift recovery so feed the child as often as possible
- Advise involvement of an IBCLC or other breastfeeding specialist to assess for and manage risk factors such as inadequate milk transfer
- Advise bath/shower in warm water and massage of the painful area (an electric toothbrush is effective) to help milk flow
- If admission is required it is important to keep a breastfeeding dyad together so feeding can continue (for resolution of mastitis, nutrition of child, and mental/long term health of both)
Non lactational mastitis
- Advise women who smoke to stop (smoking is a major risk factor)
- Identify and manage any predisposing factors e.g. nipple damage from psoriasis and eczema, Raynaud's Disease of the nipple or infection
- S. Aureus carriage: send nasal swabs
- Arrange referral to one of the breast clinic so that further management can continue
- This appointment can be made through xxxxxxx during office hours