Mastitis and Breast Abscess

 Top Tips for GPs holding a 2WW Conversation 

Macmillan 2WW guidance

Scope:

• the initial presentation of benign and malignant symptomatic breast diseases in adult women
• when to refer patients for exclusion of breast cancer and the process for excluding breast cancer in the specialist diagnostic breast clinic
• primary and secondary care management of common benign breast diseases
• management of breast conditions that present symptomatically

Out of scope:

• any aspect of screening, either in the general population or in women at high risk due to family history or genetic susceptibility [1]
• management of confirmed breast cancer − see 'Breast cancer NS MOM' pathway

Clinical features:

• breast symptoms may be due to benign or malignant disease [2]
• benign breast conditions can have clinical features similar to cancer [2]
• both male and female patients may present with breast symptoms − breast cancer is rare in males but the possibility should not be overlooked [3]
• when assessing and managing breast conditions, the clinician should stay alert for features suspicious for malignancy, and if present, refer the patient to the diagnostic breast clinic [3]
• in the diagnostic breast clinic, the patient is assessed by a specialist multidisciplinary team on the basis of clinical features, and by imaging, core biopsy, or tissue sampling [1]
• benign breast conditions include:
  • benign breast pain [2]
  • mammary duct ectasia [2]
  • galactorrhoea [2]
  • benign intraductal papilloma (causes nipple discharge) [4]
  • benign tumours, commonly fibroadenoma [2]
  • fibrocystic nodularity [5]
  • mastitis [2]
  • benign cysts [2]
  • breast abscesses [5]
  • nipple eczema [5]
  • benign skin and nipple distortion [4]
  • haematoma [4]
  • fat necrosis [4]
  • diabetic mastopathy (rare, causes lumpiness) [4]
  • phyllodes tumour (commonly benign but can sometimes be malignant) [4]

Incidence and prevalence:

• approximately 3 in 100 females present to a GP with breast problems in the UK each year [4]
• breast pain without underlying pathology may affect approximately 70% of women in their lifetime [6] 
• prevalence of breast pain is highest in females age 30-50 years [6]

Management:

• management depends on the diagnosis [4]
• management of benign conditions falls into three categories:
  • conservative management (including symptomatic medication, advice, and 'watch and wait') in primary care, providing that there are no features that indicate investigation for malignancy − in general, if conservative management is ineffective, referral to diagnostic breast clinic is indicated [4]
  • for troublesome benign disorders that have a cyclical component, such as breast pain, hormonal therapy may be attempted if first-line management is not successful [7]
  • surgical management or radiological intervention may be appropriate for some disorders where an anatomical abnormality is present, eg:
    • ductectomy for mammary duct ectasia associated with ongoing nipple discharge and reduced quality of life [4]
    • lumpectomy for large fibroadenomas [4]
    • ultrasound-guided repeat aspiration for abscesses [1]
    • needle aspiration for symptomatic cysts [5]

Map of Medicine is not responsible for the correctness or accuracy of any content uploaded, referred to or linked to from the system.

Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties

 UHB Patient Information Leaflet

NBT Patient Information Leaflet

• Mastitis  (URL) from NHS Choices
• Breast cancer (URL) from Macmillan Cancer Support at www.macmillan.org.uk
• Breast cancer (URL) from Cancer Research UK at www.cancerhelp.org.uk
• 'Breast lumps' (PDF) from Patient UK at http://www.patient.co.uk
• 'Breast pain' (PDF) from Patient UK at http://www.patient.co.uk

 NSCCG sign off form 2017

Updated in line with NICE Guideline NG12: Suspected cancer: recognition and referral to coincide with updated  BNSSG 2WW Referral forms

Date of publication: 31-Jan-2014

This care map has been updated to include evidence from the following guidelines:

• [2] Institute for Clinical Systems Improvement (ICSI) . Diagnosis of breast disease. Bloomington, MN: ICSI; 2012.
• [3] Department of Health (DH), Willet AM, Michell MJ et al. Best practice diagnostic guidelines for patients presenting with breast symptoms. London: DH; 2010.
• [5] University of Michigan Health System. Common breast problems. Ann Arbor, MI: University of Michigan Health System; 2013.
• [7] Clinical Knowledge Summaries (CKS). Breast pain - cyclical. September 2012. Newcastle upon Tyne: CKS; 2012.
• [8] National Comprehensive Cancer Network (NCCN). Breast cancer screening and diagnosis. Version 2. Fort Washington, PA: NCCN; 2013.

Further information was provided by the following references, including practice-based knowledge:

• [1] Practice-informed recommendations. London; 2014.
• [6] Goyal A. Breast pain. Clin Evid 2011; pii: 0812.
• [11] National Cancer Action Team, Breakthrough Breast Cancer, NHS Improvement. Going further on cancer waits: the symptomatic breast two week wait standard. Leicester: NHS Improvement; 2009.
• [17] Department of Health (DH). Improving outcomes: a strategy for cancer. London: DH; 2011.

 Mastitis is defined as an inflammation of the breast which may or may not be caused by bacterial infection [9].

Clinical presentation may include [9]:

• tender, hot, swollen area of the breast
• temperature of 38.5°C or greater
• chills
• flu-like aching

There are two main types of mastitis:

• lactational mastitis [9]:
  • common condition in women who are lactating
  • occurs most often during the first 6 weeks after childbirth
  • is usually caused by Staphylococcus aureus
  • predisposing factors may include [9]:
    • inadequate expression of milk from the breast, leaving residual milk which may become infected
    • cracked or fissured nipples, allowing entry of bacteria into the breast
    • infrequent or missed feeding
• non-lactational mastitis [4]:
  • mastitis occurring in the absence of lactation
  • presents as an erythematous, tender, indurated segment of the breast
  • often anaerobic infection
• ductal ectasia or periductal mastitis are both forms of non-lactational mastitis that are [4]:
  • more common among postmenopausal women
  • also seen in young women who smoke
  • may present with nipple discharge, nipple distortion, subareolar lump, or mastitis
• other examples of non-lactational mastitis include [4]:
  • tuberculosis mastitis
  • granulomatous mastitis

Symptoms of mastitis presenting alongside a lump indicate the possibility of an abscess [1].

 Ask the patient [4]:

• whether she is, or has recently been, pregnant or lactating
• whether other features (eg lump) are present (consider the possibility of an abscess if a lump is present alongside symptoms of mastitis [1])
• the duration of symptoms
• whether symptoms are unilateral or bilateral
• about nursing technique (inadequate breast drainage is a risk factor for mastitis) [9]
• about nipple changes (nipple fissuring is a risk factor for lactational mastitis) [9]
• whether she smokes (smoking is a risk factor for periductal mastitis) [4]

Ask about aetiological factors for breast disease, including:

• history of trauma to chest area [2]
• history of enlarged lymph nodes [4]
• personal history of breast cancer [3]
• number of previous benign breast biopsies [8] and personal history of breast biopsy or surgery [1]
• history of risk factors for breast cancer, including:
  • age (risk increases with age) [8]

  • personal history of ductal hyperplasia on previous biopsies [2]

  • prior radiation before age 30 years [2] (US guidelines specify between age 10−30 years [8])
  • family history of:
    • breast cancer in first-degree relatives [2]
    • breast and/or ovarian cancer (particularly in a first-degree relative who developed the disease before age 50 years − this is an extremely high-risk group who should be referred for genetic testing and counselling [2])
  • genetic predisposition [8] (carrier of mutated breast cancer genes [1])
  • race [8], eg Jewish ancestry (increased risk of hereditary breast cancer in Ashkenazi Jews) [4]
  • age of menarche [8] (risk increases with earlier menarche [4])
  • obstetric history [8] (nulliparity and first live birth after age 30 years are risk factors [4])
  • menopausal status [4]:
    • ask if the patient is pre-, post-, or peri-menopausal
    • note age of menopause if the patient is postmenopausal (postmenopausal females are at higher risk and late menopause is a risk factor)
  • alcohol intake [4]
  • hormone replacement therapy (HRT) or oral contraceptive use [2,3]
  • obesity and weight gain [4]
  • current medications [2]
  • date of last mammogram, if any [3]

 Before the examination [4]:

• document the current phase of the menstrual cycle
• consider whether a chaperone should be present (seek patient’s consent before asking a chaperone to attend the examination)

As part of the physical examination:

• perform a bilateral examination, even if symptoms are unilateral [3]
• inspect and palpate the patient’s breasts, neck, chest wall, and arms [2] whilst the patient is positioned in an upright position, and again with the patient supine [2]
• include examination of the lymph node basins [8]
• examine the breasts with the flat part of the fingers; gently but firmly examine each quadrant and the nipple and areolar complex with regard to shape, size, texture, position within breast, mobility, and tenderness [4]
• delineate and document any breast masses with regard to shape, size, texture, position within breast, mobility, tenderness, and whether mass is attached to skin or underlying structures [4]
• compare the breasts and take note of any asymmetry [4]
• look for the following:
  • masses [2] (consider possibility of an abscess [1])
  • nodules [2]
  • skin retraction (may be revealed by asking the patient to place her arms on her hips, contract her pectoral muscles, and then raise her arms) [4]
  • peau d'orange [8]
  • swelling [2]
  • redness or inflammation of the skin [2]
  • nipple discharge [2]
  • nipple erythema, eczema-like changes, or excoriation/ulceration [8]
  • nipple retraction or distortion
  • fungation [4]
• examine the axillae by holding the patient's arm and opening up the axilla [4]
• examine the supraclavicular fossae for thickening or lymphadenopathy − if lymphadenopathy is noted, a full examination of the cervical nodes should be performed [4]
• examine the skin covering the breast for lesions that may be staining the patient's clothes and mimicking nipple discharge, such as:
  • Paget's disease [2]
  • insect bites [4]
  • local infections [5]
  • eczema [5]

 Consider the possibility of a breast abscess if symptoms of mastitis present alongside a lump and consider referring patient immediately as an emergency, for same-day specialist assessment and treatment - see local information

Evidence is currently lacking that describes clear criteria for urgent referral in females with untreated suspected mastitis in the absence of a discrete lump [4].

Review the patient within a few days (after empirical treatment has begun) and defer the decision to refer until then; the decision can then account for any response to treatment [9].

The following additional features are highly suspicious − refer via 2WW pathway if any of these are present [10]:

• Age 50 and over with any of the following symptoms in one nipple only:
  • discharge - clear or blood
  • retraction - new onset and sustained (nipple distortion may be a consequence of mastitis, and should resolve)
  • Other changes of concern
• Age 30 and over with an unexplained breast lump with or without pain
• Age 30 and over with an unexplained lump in the axilla
• Have skin changes which suggest cancer
• Males aged 50 and over with unilateral firm sub areolar mass with/without nipple distortion and skin changes

Local administrative information

 Suspect an abscess if a well-defined area of the breast remains hard, red, and tender despite appropriate management [9].

Manage patients initially according to the following criteria [1]:

• patients with a suspected breast abscess should be referred for same-day specialist assessment and treatment - see local information:
  • prescribe antibiotics, eg flucloxacillin for patients who are systemically well, if out of hours, and ensure patient is seen the next morning
  • patients do not need to be seen out of hours unless:
    • systemically unwell
    • possible imminent skin breakdown
    • immunocompromised, eg on chemotherapy

Local administrative information

 Local administrative information

 2WW Breast services are available at Southmead (NBT) or Weston (WAHT)

Suspected Cancer referral - refer via 2WW

• Age 30 and over with an unexplained breast lump with or without pain
• Age 30 and over with an unexplained lump in the axilla
• Have skin changes which suggest cancer 
• Age 50 and over with any of the following symptoms in one nipple only:
• discharge - clear or blood
• retraction - new onset and sustained (nipple distortion may be a consequence of mastitis, and should resolve)
• Other changes of concern 
• Males aged 50 and over with unilateral firm sub areolar mass with/without nipple distortion and skin changes

Symptomatic Breast Referral (non-suspected cancer referral via referral service but can use 2WW form)

• Aged under 30 with an unexplained breast lump with or without pain
• Other (please detail)

All breast referrals are seen within two weeks

  2WW referral forms are available as EMIS templates

 In systemically well patients where symptoms of mastitis do not improve within 12-24 hours or the patient is acutely unwell, prescribe antibiotics. http://bnssgformulary.nhs.uk/BNSSG Antimicrobial Guidelines/ (see node below - commence antibiotic therapy)

 Encourage the patient to take appropriate medications as indicated, although they may be reluctant to take them whilst breastfeeding [9].

Recommend the following:

• analgesics such as paracetamol may ease pain
• ibuprofen may be more effective in reducing inflammation

Mastitis associated with breast feeding: Flucloxacillin 500 mg QDS for 7 days and then review

If woman or child is penicillin allergic: Clarithromycin 500 mg BD for 7 days and then review

In non-lactating mastitis: Flucloxacillin 500 mg QDS PLUS Metronidazole 400 mg every 8 hours

 Effective milk removal is important in resolving the symptoms of mastitis [9]. 

Provide the following advice [9]:

• mastitis does not preclude breastfeeding

• the patient should breastfeed or express milk frequently

• positioning the infant at the breast with the chin or nose pointing to the blockage will help drain the area

• massaging the breast during a feed with an edible oil or nontoxic lubricant may be helpful (massage should be directed from the blocked area moving toward the nipple)

• patients unable to breastfeed should express milk from the breast, as sudden cessation of breastfeeding leads to a greater risk of abscess development than continuing to feed

• in breastfeeding women, treat fissured or dry nipples with emollients and teach good nipple care to help prevent recurrence

Other supportive measures include [9]:

• rest, with possible practical help at home
• adequate fluids
• nutrition
• application of a heat pack to the breast prior to feeding
• application of a cold pack to breast after feeding to reduce pain and oedema

 It is important to formally reassess the patient within a few days of starting treatment as a clinical response to antibiotics should be seen with 2-3 days [9].

Failure to respond requires referral for diagnosis and assessment. Failure to respond could be due to [9]:

• inflammatory or ductal malignancy
• breast abscess
• resistant bacteria, eg Meticillin-resistant Staphylococcus aureus (MRSA) [5]
• unusual non-cancerous disorders that mimic acute bacterial mastitis, such as sarcoidosis and other granulomatous diseases [4]

 If symptoms do not improve after 2-3 days [9]:

• consider urgent referral to a breast clinic for further investigations
• request a breastmilk culture and antibiotic sensitivities:
  • a sample can be collected by hand-expressing midstream into a sterile container
  • a small quantity of the initially expressed milk should be discarded to avoid contamination of the sample with skin flora and care should be taken not to touch the inside of the container when expressing subsequent milk
• prescribe antibiotics while culture results are pending, taking into consideration local resistance patterns for Meticillin-resistant Staphylococcus aureus (MRSA)

NB. All Breast referrals are seen within two weeks

Breast services are available at Southmead (NBT) or Weston (WAHT)

 If symptoms of mastitis start to improve after 2-3 days, continue treatment and ensure that complete resolution occurs after a single antibiotic course [9].

If features have not resolved, or if mastitis is recurrent, refer urgently to breast clinic [9].

 The standard RSS referral form is available as an EMIS template

NB. All Breast referrals are seen within two weeks