A 30-Year-Old Woman With a Lactational Breast Abscess Managed With Adjunctive Negative Pressure Wound Therapy (Vacuum-Assisted Closure)

Introduction

A breast abscess is a localized collection of purulent material, often palpable through the skin surface [1]. It is more frequently observed in women during lactation and in the presence of breast infections, although it can also occur outside these circumstances. The incidence of lactational mastitis is estimated at 2% to 3% of breastfeeding women, and 5% to 11% of these cases progress to breast abscess formation. The average onset age is 32 years. Most abscesses develop during the second week after the birth of a first child [2]. Lactational breast abscesses are commonly associated with Staphylococcus aureus or Streptococcus species, with a growing number of methicillin-resistant strains (MRSA). In contrast, non-lactational abscesses usually involve mixed bacterial flora, including S. aureus, streptococci, and anaerobic bacteria [2].

Breast abscesses during lactation result from bacterial mastitis or diffuse inflammation of connective tissue (phlegmon), ultimately leading to the formation of a localized, infected fluid collection that requires drainage. It is estimated that in approximately 3% to 11% of women with mastitis, an abscess develops [1]. Risk factors for breast abscess include lactation, obesity, smoking, and nipple piercings. A higher incidence is also reported among African American women [3]. Patients with breast abscess typically present with breast pain and localized warmth. On physical examination, erythema and edema are observed, and a mobile, well-defined mass is usually palpable. Typical symptoms of an abscess include fever, nausea, vomiting, and serous discharge from the nipple or the area of swelling. Tachycardia can also occur [1,2].

The most important elements in diagnosing a breast abscess are a thorough medical history and physical examination. Patient history often reveals repeated use of various antibiotics and prolonged inflammation [2]. Suspicion of an abscess is an indication for breast ultrasonography. An abscess appears as a hypoechoic lesion, possibly well-defined, irregular, and poorly circumscribed. Fine needle aspiration biopsy may be used for diagnostic and therapeutic purposes. The presence of purulent fluid during aspiration confirms a breast abscess. The sample may undergo cytological and microbiological examination to confirm or exclude infection [4].

The primary method of treating a breast abscess is drainage. In cases of lactational abscesses smaller than 3 cm, needle aspiration can also be used [2]. Recommended empirical antibiotic therapy includes dicloxacillin, cephalexin, and amoxicillin-clavulanate, which is particularly effective due to its broad spectrum. In cases of MRSA infection, clindamycin or vancomycin is advised. Continued breastfeeding is generally recommended, as it does not worsen the patient’s condition [5].

Negative pressure wound therapy (NPWT), also known as vacuum-assisted closure, is a treatment method that uses sub-atmospheric pressure applied to the wound and its surroundings to support healing [6]. The mechanism of NPWT involves generating negative pressure within the wound, namely pressure lower than atmospheric. This is achieved through the use of a vacuum-assisted closure system, consisting of an electrically powered suction device with a canister that allows the regulation and control of pressure and collection of wound exudate [7]. NPWT also uses a polyurethane foam with pore sizes of 400 to 600 μm, which is shaped to match the wound. Its role is to evenly distribute the negative pressure and maintain the position of the drain connecting the device to the wound. The final component is a semi-transparent, adhesive dressing that seals off the wound surface and enables vacuum generation [6].

NPWT promotes wound healing on several levels. Airtight isolation of the wound combined with drainage reduces the bacterial burden in the wound bed, thereby decreasing infection risk. It also reduces the need for antibiotics in patients receiving NPWT. It relieves wound tension and maintains appropriate moisture. NPWT increases local blood flow, promotes collagen synthesis, and improves microcirculation. By removing accumulated fluid, it also reduces local edema, enhancing lymphatic and blood flow [6].

NPWT is used across various medical fields. It is commonly used in the management of acute wounds, such as open fractures and lacerations. It can be applied to treat limb ulcers, including diabetic foot ulcers, helping reduce wound size and promote deep healing. NPWT is also used in managing postoperative wounds, skin grafts, and burns. In breast surgery, NPWT is commonly applied in oncological procedures and in supporting wound healing following plastic breast surgery [6,8,9]. However, we found no reports in the available literature on the use of this therapy for lactational breast abscesses. The aim of this report is to present the use of NPWT in the management of a lactational breast abscess.

Case Report

A 30-year-old female patient presented to the general surgery outpatient clinic on August 26, 2024. She reported a subfebrile temperature and pain and warmth in the right breast since August 13, following diagnostic work-up for a focal lesion in the right breast. A core needle biopsy had excluded malignancy but was complicated by the development of a hematoma.

On the day of presentation, the patient reported a palpable mass in the right breast. Physical examination revealed no axillary lymphadenopathy, and the skin over the lesion showed no signs of inflammation. The patient reported using cold compresses and compression therapy, with minimal improvement. Her obstetric history included a vaginal delivery in 2023. She had been breastfeeding up to the time of the visit and had a long-term history of hypothyroidism. The main risk factor for the development of a breast abscess in this patient was the core needle biopsy. No other predisposing factors were identified.

Ultrasound examination performed during the surgical consultation revealed a hypoechoic, heterogeneous lesion located 1 cm below the skin surface in the medial upper quadrant of the breast, measuring approximately 7×2.5 cm, without a clearly defined capsule (Figure 1). This lesion had not been described in previous ultrasound studies. During the visit, needle aspiration was performed, yielding purulent material. Based on the clinical findings, ultrasound-guided abscess drainage was performed, and the material was sent for microbiological culture, which revealed no bacterial growth. The patient was advised to continue breastfeeding and was started on empirical antibiotic therapy with cefadroxil 500 mg every 12 hours for 10 days, pending culture results. Following receipt of the negative microbiological culture results, antibiotic therapy was discontinued after 7 days.

At a follow-up visit on October 15, the patient exhibited no systemic symptoms; however, ultrasonography revealed a persistent fluid collection measuring 5×3.5 cm.

Five days later, ultrasound-guided abscess drainage was repeated, yielding approximately 3 mL of purulent material, which was sent for cytological analysis. The cavity was irrigated thoroughly with sodium hypochlorite, and a NPWT dressing was applied with continuous negative pressure at −120 mmHg (Figure 2). Cytological examination confirmed the presence of purulent-necrotic exudate.

On October 31, the NPWT dressing was removed. No purulent discharge was noted in the device’s canister, and ultrasound imaging showed slight regression of the lesion. Following discussion with the patient and re-evaluation of therapeutic options, a new NPWT dressing was applied on November 9 with continuous negative pressure at −90 mmHg. Prior to this, the abscess cavity was debrided with a Volkmann curette and irrigated thoroughly with sodium hypochlorite. After 3 days of therapy, NPWT was discontinued. Ultrasound revealed only a residual hypoechoic area at the site of the former abscess. The wound was disinfected with hypochlorous acid (Microdacyn) and dressed with a foam dressing. In the following days, a milky discharge was observed from the incision site made for NPWT application. Two days after NPWT removal, a milk fistula was diagnosed. The patient was instructed to irrigate the wound with sodium hypochlorite and change multilayer silicone contact foam dressings every 2 days.

On November 25, the patient subjectively reported significant regression of the mass at the former abscess site. On December 9, the patient reported complete cessation of the discharge, and the fistula was considered healed. Throughout the entire period, the patient continued breastfeeding, disinfected the wound with sodium hypochlorite, and used absorbent dressings.

The wound was considered closed and healed on December 9, 2024, following 3.5 months of treatment. A follow-up breast ultrasound was scheduled for February 2025.

Discussion

This case demonstrates the potential for safe application of NPWT in the management of a breast abscess during lactation, while simultaneously preserving ongoing breastfeeding.

According to the recommendations of the World Health Organization and the United Nations Children’s Fund, the first breastfeeding session should occur within the first hour after birth, followed by exclusive breastfeeding for the first 6 months of life. Breastfeeding along with complementary feeding may continue beyond the second year of life [10]. Among children under the age of 5 years, an estimated 820 000 deaths could be prevented annually if children aged 0 to 23 months were breastfed, and 20 000 mothers could avoid developing breast cancer [11].

Data collected by the Centers for Disease Control and Prevention (CDC) indicate that among infants born in 2019, 83.2% were initially breastfed; however, by 6 months of age, only 24.9% were exclusively breastfed [11]. In a 2023 study by Roberts et al, the most common reasons for early cessation of breastfeeding were feeding difficulties, particularly trouble latching, and reported improvement in maternal mental health after stopping breastfeeding [13]. Other CDC studies cite social norms, such as the perception that bottle feeding is “normal” and socially acceptable, as reasons for not breastfeeding [14].

Over the past decade, the percentage of women breastfeeding exclusively for the first 6 months rose to 48% in 2023, approaching the World Health Assembly’s 2025 target of 50% [15].

The benefits of breastfeeding are diverse. Human milk has a positive impact on the health of both mother and child in the short and long term. It helps protect newborns from infectious diseases such as diarrhea and respiratory infections. The absence of breastfeeding is a proven factor in increased neonatal mortality. Long-term benefits for infants include a reduced risk of developing type 2 diabetes and leukemia. For mothers, breastfeeding lowers the risk of breast and ovarian cancers and diabetes [16].

Breastfeeding is the gold standard for infant nutrition up to 2 years of age. However, mastitis affects 2% to 33% of breastfeeding women, and 3% to 11% of them experience complications in the form of breast abscesses [17,18]. Meanwhile, in Europe, the average maternal age at first childbirth continues to rise: in 2019 it averaged 29.4 years, and, in some countries, such as Italy, reached 31 years [19].

Lactation may be disrupted by various factors; however, imaging techniques such as ultrasonography and magnetic resonance imaging are safe and are recommended as first-line diagnostic tools. Ionizing radiation from computer tomography or nuclear medicine generally does not reach levels that would pose a threat to lactation and should not prevent necessary diagnostics [20].

According to the guidelines of the Academy of Breastfeeding Medicine, the recommended treatment for a breast abscess includes drainage of the collection, with continued breastfeeding. Antibiotic therapy may be administered for 10 to 14 days. Tissue edema and abnormal discharge can persist for several weeks [1]. This approach is cost-effective due to its outpatient nature, avoids cosmetic deformities, and reduces the risk of abscess recurrence, compared with surgical methods. Additionally, it facilitates a faster return to breastfeeding [21].

NPWT is an increasingly used technique. In the treatment of wounds located on the breast, NPWT is applied, for example, following breast reconstruction with implants, where it helps reduce the risk of complications [8]. One major advantage of NPWT therapy is the possibility of treating patients in an outpatient setting and significantly shortening the wound healing process [22]. In a 2024 case reported by Cimmino et al, NPWT reduced discharge, promoted faster healing, and enabled reimplantation of the breast following a complicated periprosthetic infection [23]. In another case from 2024, Akgul et al described the use of NPWT in a woman with necrotizing fasciitis of the lactating breast. After debridement of necrotic tissue, mastectomy was successfully avoided [24].

To the best of our knowledge, the case presented in this report is the first of its kind. We found no other reports of NPWT being used in the treatment of lactational breast abscesses.

Conclusions

Lactational breast abscess is a common complication in postpartum women. The primary treatment approach involves effective drainage of the abscess cavity combined with the continuation of breastfeeding. NPWT is an increasingly utilized modality across various medical disciplines. Its application in the management of lactational breast abscesses appears to be both feasible and effective. Further studies involving larger patient cohorts are required to better evaluate its effectiveness and safety.