Breast infections in non-lactating women.

BACKGROUND: Breast infection in lactating mothers is a common entity which in the majority of cases can be explained by ascending infections. However, it has been noticed that the number of non lactating women presenting with breast abscesses is rising. This study attempts to explore the sensitivity pattern of organisms and underlying cause of breast infections in non-lactating women.
MATERIALS AND METHODS: This review was undertaken at King Fahd of the University, Alkhobar, Saudi Arabia between 1991-2003. All patients presenting with breast infections were included. Medical records, operative notes, cultures, histopathology reports and outcome were reviewed.
RESULTS: The number of patients presenting with breast infections accounted for 179(3.5%) out of the total number of patients 6314 with variable breast complaints. Infection occurred in 136(76%) lactating women (Group I) ,while Non lactating (Group II) breast infections accounted for 43(24%). Age ranged from 24 years to 52 years. Underlying clinical conditions were found in 26 patients(60%) in Group II namely granulomatous mastitis13(50%), duct ectasia4 (15.3%), pregnancy3(11.5%), fat necrosis1(3.8%), diabetes3 (11.5%) and breast cancer 2(7.6%). The pattern of culture results was different in the two groups, from differing causative organisms namely staphylococcus aureus as the commonest organism in both groups, in comparison to such uncommon organisms as Klebsiella pneumonae, Peptococcus magnus, Streptococcus group B, Entro-bacter cloacae, Methicillin resistant staphylococcus aureus (MRSA) and Mycobacterium tuberculosis occurring in group II only. Fortunately, all organisms were sensitive to antimicrobial therapy.
CONCLUSION: Breast infection in non-lactating women is an infrequent but recognized clinical entity that deserves special attention. An underlying clinical condition should always be sought and treated. Indeed, in addition to cultures, radiological modalities such as ultrasonographic imaging may provide specific diagnosis and aid the management.

INTRODUCTION

Acute inflammation of the breast usually occurs in nursing women, and to a lesser extent in non-lactating women, mostly in the reproductive age group and less commonly in menopausal women. This can be attributed to the increased activity of the breast tissue in response to female hormones. It may range from mild superficial mastitis to deep abscesses. The distinction between mastitis and frank abscess is of great importance since the management of these two entities varies from antibiotics to drainage either by aspiration or classical incision. The combination of antimicrobial therapy and drainage is the mainstay of treatment. Treatment with antimicrobials without drainage may lead to the surgical condition termed “Antibioma” which mimics malignancy both clinically and radiologically.

MATERIALS AND METHODS

This review was undertaken at King Fahd of the University, Alkhobar, Saudi Arabia between 1991-2003. All patients presenting with breast infections were included. Medical records, operative notes, cultures, sensitivity to antimicrobials, histopathology reports and response to therapy were reviewed.

Laboratory methods: all isolates obtained were identified according to colonial and microscopic morphology. The disc diffusion method adopted by the National Committee for Clinical Laboratory Standards (NCCLS) was used. Identified isolates were then tested against Erythomycin, Cefoxitin, Trimethoprim-Sulfa methoxazole, Methicilin, Tetracycline, Ampicillin, Augmentin (Co-Amoxiclav), Gentamycin, Ciprofloxacin, INH (Izoniazid), Riphampicin, Ethambutol, Streptomycin, Chloramphenicole, Vancomycin, Amikacin, Penicillin, Clindamycin, Metronidazole.

RESULTS

The total number of patients diagnosed as infections accounted for 179(2.8%) from the total number (6314) presenting with a variety of breast complaints.

The majority of cases presenting with breast infections 136(76%) were lactating women (Group I).

Non-lactating (Group II) breast infections accounted for 43(24%) of all breast infections, with ages ranging between 24-52 years. In Group I, no underlying cause was identified and histopathology reported abscess cavity with non specific inflammation, whereas underlying conditions were reported in 26(60%) of Group II namely granulomatous mastitis13(50%), duct ectasia4 (15.3%), pregnancy3(11.5%), fat necrosis 1 (3.8%), diabetes 3 (11.5%) and breast cancer 2 (7.6%).

The pattern of culture results was different in the two groups, varying from no growth in33 (24%) patients to 103(75%) patients in whom Staphylococcus aureus was isolated. Similarly, Staphylococcus aureus was the most common organism isolated in Group II, having been reported in 24(56%) in patients followed by such less uncommon organisms as Streptococcus group B in 6(15%), Klebsiella pneumonae in 4(9%), Mycobacterium tuberculosis in 4(9%), MRSA in 3(7%), Peptococcus magnus1(2%) and Entro-bacter cloacae in 1(2%).

Granulomatous mastitis diagnosed in 13(60%) of Group II was based on the recurrent nature of the breast infections and confirmed by histopathological reports. They were treated accordingly with the appropriate antimicrobials and repeated surgical drainage. Complete healing occurred in 3- 6months.

Community acquired Methicillin-resistant Staphylococcus aureus (MRSA) was also isolated in 3(7%) in this group. Fortunately, all organisms were sensitive to antimicrobial therapy (Table 1).

Table 1

Organisms and sensitivity pattern in non-lactating breast infections

DISCUSSION

Due to the delicate nature of the active breast tissue, prompt and appropriate management of breast infections is essential. Delay or inadequate management may lead to tissue destruction, chronic infections, periductal fistulas and breast deformities.

Pyogenic infections are the commonest with a variety of causative bacteria. However, many other uncommon organisms have been reported. The infrequent non lactating infections can be divided into those occurring centrally in the periareolar region and those affecting the peripheral breast tissue. The former is characterized by periductal inflammation. Hence the term periductal mastitis. The distinction between mastitis and frank abscess is of great importance since the management of these two entities varies from antibiotics to drainage either by aspiration or incisions.

Tuberculous mastitis remains a problem in developing countries, occurring mostly unilaterally with a wide range of differential diagnoses from duct ectasia to malignancy. Diagnosis is mainly based on the histopathological demonstration of tubercules, caseation and granulomatous formation.1

Idiopathic granulomatous lobular mastitis has recently become a well-recognized entity. Clinically and radiologically, it may mimic breast cancer. Patients present with repeated attacks of recurrent breast abscesses. The true prevalence in Saudi Arabia is difficult to determine since most reported series are hospital-based with the reported incidence 1-2% of all cases presenting with breast infections.2 Patients are generally treated as recurrent breast abcesses.

Recent studies have shown the emergence of Methicillin-resistant Staphylococcus aureus (MRSA) as a community pathogen, with soft tissue infections as a predominant presentation. Fortunately, the community acquired MRSA are susceptible to a greater number of antimicrobials compared to the hospital acquired isolates.3

Other rare organisms infesting the breast include Actinomycosis, Nocardia Astreiodes and Paragonimiasis.4–6 Although breast involvement with brucellosis in animals is not uncommon, cutaneous and soft tissue manifestations are extremely rare in humans.7

Breast abscess like other infections can become florid in immunosupressed patients or those with indwelling prosthetic devices just as in gram negative infections lead to fatal septicemia in HIV- infected patients who may initially present with breast abscess; or patients who get infected with the normal constituents of skin flora such as Corynebacterium striatum and Helcococcus kunzii due to compromised immunological state.8–10

Current reported evidence showed the close link between smoking and periductal mastitis, 90% of which occurs in smokers as compared to 38% in non-smokers. It has been suggested that smoking either directly or indirectly damages the wall of the subareolar breast ducts making them vulnerable to infections. Peripheral non-lactating breast abscesses are less common, and are commonly associated with co-morbid conditions such as diabetes, rheumatoid arthritis, steroid therapy, granulomatous lobular mastitis and trauma.11

Currently, with the latest fashion of nipple piercing, the incidence of non-puerperal mastitis has increased. The risks of piercing is under documented, and may be as high as 10-20% in the months following the procedure.12

Radiological investigations such as mammography is limited in this setting due to the inflammatory pain which makes it difficult to achieve adequate compression for a good exposure. In addition, mammographic features in infections are nonspecific demonstrating speculated masses that can be indistinguishable from infiltrating cancer. However, ultrasonography has been shown to play an important role in the management of patients with acute inflammation. The ultrasonic findings of interstitial fluid and a hypoechoic wall are relatively specific for breast abscesses. Those with no ultrasonic evidence of abscess can be successfully treated with antibiotics, while the presence of ultrasonographic fluid collection indicates the need for intervention.1314

In the era of minimally invasive surgery, percutaneous drainage has proven a safe and effective alternative to incision and drainage in acute abscesses, while chronic abscesses are best treated with the classical means of drainage.15 The method of percutaneous aspiration combined with irrigation and instillation of antibiotics has proved effective in 96% of cases reported in one series.16

In this current study, all patients underwent emergency incision and drainage as well as biopsy of the abscess cavity without any radiological aids, a variety of organisms were isolated, staphylococcus aureus being the most common in both groups, followed by, mycobacterium tuberculosis, MRSA, klebsiella pneumonae, peptococcus magnus, streptococcus group B and entero-bacter cloacae in group II only. Underlying conditions were treated, wounds were left open to heal with secondary intention. All patients received postoperative antibiotics based on the sensitivity pattern and were discharged 3-4days with daily dressing until healing is complete.

In retrospect, many of these patients could have been successfully treated with ultrasonographic guided repeated aspiration which would have spared them the remote surgical morbidity, hospital stay, the inconvenience of the daily dressing as well as the hospital cost.

It should also be remembered that though breast infections may sound simple, more serious conditions such primary squamous cell carcinoma, primary breast lymphoma and ductal carcinoma have been reported to present initially with breast abscess masking the original diagnosis mandating breast cytological or histological analysis.1718

In conclusion, non-lactating breast infections are an infrequent clinical entity occurring in women with obscure underlying predisposing condition. The pattern of organisms are different from those occurring in lactating women. However, the isolates are thus far more sensitive to the commonly used antimicrobial therapy. Investigational facilities such as ultrasonography, cytological and histological analysis should be fully utilized to rule out an underlying condition.