Lactational phlegmon: A distinct clinical entity affecting breastfeeding women within the mastitis‐abscess spectrum

We aimed to describe the presentation and treatment of lactational phlegmon, a unique complication of mastitis in breastfeeding women that may require surgical management. We retrospectively analyzed medical charts of breastfeeding women treated by a single breast surgeon for lactational phlegmon or the related conditions of abscess or uncomplicated mastitis (UM) from July 2016 to October 2018. Demographic variables and treatment details were analyzed using ANOVA and Pearson's Chi‐square test. Ten women with lactational phlegmon (19.2%), 15 women with abscess (28.8%), and 27 women with UM (51.9%) were identified. Phlegmon presented as a tender, erythematous, and nonfluctuant mass in a ductal distribution. Ultrasonography demonstrated an ill‐defined, complex fluid collection. Epidemiologically, women with phlegmon were similar to patients with abscess and UM. Women with phlegmon reported more intense deep breast massage than patients in the other two groups, but significantly lower rates of breast pump use than women with abscess (30.0% vs 80.0%, P < .05). Relative to women with UM, patients with complicated mastitis (CM, defined as phlegmon or abscess) reported greater utilization of nipple shields (36.0% vs 11.1%, P < .05). Treatment of phlegmon entailed effective milk removal, antibiotics (range 10‐30 days), and close follow‐up until both clinical and radiographic resolution (range 8 days to >3 months), with biopsy of persistent masses. Antibiotic duration was significantly longer for patients with phlegmon compared to those with UM (mean 15.0 days vs 9.7 days, P < .05). Two phlegmons coalesced into abscesses within 1 week of diagnosis. Lactational phlegmon is a complication of mastitis in breastfeeding women that is distinct from abscess and UM. Optimal treatment consists of an extended course of antibiotics and close follow‐up to monitor for coalescence into a drainable fluid collection and/or persistence of mass requiring biopsy.     

Diagnosis and treatment of patients with prostatic abscess in the post‐antibiotic era

We reviewed the pathogenesis, clinical presentation, treatment options and outcomes of prostatic abscess in the post‐antibiotic era, focusing on how patient risk factors and the emergence of multidrug‐resistant organisms influence management of the condition. A MEDLINE search for “prostate abscess” or “prostatic abscess” was carried out. Prostate abscess is no longer considered a consequence of untreated urinary infection; now, men with prostatic abscess are typically debilitated or immunologically compromised, with >50% of patients having diabetes. In younger men, prostatic abscess can be the initial presentation of such chronic conditions. In older men, prostatic abscess is increasingly a complication of benign prostatic hyperplasia or prostate biopsy. Diagnosis is based on a physical examination, leukocytosis, leukocyturia and transrectal ultrasound, with magnetic resonance imaging serving as the preferred confirmatory imaging modality. Treatment of prostatic abscess is changing as a result of the emergence of atypical and drug‐resistant organisms, such as extended‐spectrum β‐lactamase‐producing enterobacteriaceae and methicillin‐resistant Staphylococcus aureus. As many as 75% of infections are resistant to first‐generation antibiotics, necessitating aggressive therapy with broad‐spectrum parenteral antibiotics, such as third‐generation cephalosporins, aztreonam or antibiotic combinations. A total of 80% of patients require early surgical drainage, frequently through a transurethral approach. In the post‐antibiotic era, prostatic abscess is evolving from an uncommon complication of urinary infection to a consequence of immunodeficiency, growing antibiotic resistance and urological manipulation. This condition, primarily affecting patients with chronic medical conditions rendering them susceptible to atypical, drug‐resistant organisms, requires prompt aggressive intervention with contemporary antibiotic therapy and surgical drainage.     

Surgical management of recurrent subareolar breast abscesses: Mayo Clinic experience

BACKGROUND: Recurrent subareolar abscess is an uncommon condition of the breast. The disease process often is managed inadequately by repeated courses of antibiotics and/or incision and drainage procedures that temporarily may relieve the abscess collection but fails to correct the primary inciting process. Repeated surgical procedures may lead to multiple scars, nipple and breast distortion without cure of the problem, or even to mastectomy. METHODS: We report a retrospective review of patients who have been treated surgically with this condition at a single institution from 1993 to 2005. RESULTS: Successful definitive treatment of retroareolar abscesses necessitates excision of the central nipple, including the obstructed ducts. CONCLUSIONS: This technique achieves a cure rate of 91% and an overall 95% satisfaction rate in the cosmetic outcome of the nipple.     

Nocardia farcinica cerebral abscess: A systematic review of treatment strategies

PurposeNocardia farcinica is an opportunistic pathogen causing mainly pneumonia in immunocompromised patients, complicated in almost one-third of the cases by a thick-walled multiloculated cerebral abscess which induces significant morbidity and mortality. This review aims to assess the optimal treatment strategy for N. farcinica cerebral abscess.MethodsReport of a case. Medline database was used to conduct a systematic review from inception to January 2020 looking for English-language articles focused on N. farcinica cerebral abscess, in accordance with the PRISMA guidelines.ResultsThe research yielded 54 articles for a total of 58 patients. N. farcinica cerebral abscess displayed three different neuroimaging patterns: a single multiloculated abscess in half of the cases, multiple cerebral abscesses, or a small paraventricular abscess with meningitis. The patients who benefited from surgical excision of the abscess showed a trend towards a lower risk of surgical revision (8% versus 31%, P = 0.06) and a lower mortality rate (8% versus 23%, P = 0.18) than patients who benefited from needle aspiration. Twenty-two percent of the patients benefited from microbiological documentation from another site with a mortality rate of 23%.ConclusionUrgent multimodal MRI is necessary in face with clinical suspicion of cerebral nocardiosis. In case of single or multiple small cerebral abscesses, microbiological documentation can be obtained with puncture of pseudotumoral visceral lesions. In case of large or symptomatic cerebral abscess, an aggressive surgical excision seems a reliable option and can be preferred over needle aspiration. Long-term antibiotic therapy with cotrimoxazole is necessary thereafter.     

Have the Organisms that Cause Breast Abscess Changed With Time?––Implications for Appropriate Antibiotic Usage in Primary and Secondary Care

Abstract: Many patients with breast abscess are managed in primary care. Knowledge of current trends in the bacteriology is valuable in informing antibiotic choices. This study reviews bacterial cultures of a large series of breast abscesses to determine whether there has been a change in the causative organisms during the era of increasing methicillin‐resistant Staphylococcus aureus (MRSA). Analysis was undertaken of all breast abscesses treated in a single unit over 2003 – 2006, including abscess type, bacterial culture, antibiotic sensitivity and resistance patterns. One hundred and ninety cultures were obtained (32.8% lactational abscess, 67.2% nonlactational). 83% yielded organisms. Staphylococcus aureus was the commonest organism isolated (51.3%). Of these, 8.6% were MRSA. Other common organisms included mixed anaerobes (13.7%), and anaerobic cocci (6.3%). Lactational abscesses were significantly more likely to be caused by S. aureus (p < 0.05). Methicillin‐resistant Staphylococcus aureus rates were not statistically different between lactational and nonlactational abscess groups. Appropriate antibiotic choices are of great importance in the community management of breast abscess. Ideally, microbial cultures should be obtained to institute targeted therapy but we recommend the continued use of flucloxacillin with or without metronidazole (or amoxicillin‐clavulanate as a single preparation) as initial empirical therapy.     

Management of Lactational Mastitis and Breast Abscesses: Review of Current Knowledge and Practice

Most breast abscesses develops as a complication of lactational mastitis. The incidence of breast abscess ranges from 0.4 to 11 % of all lactating mothers. The traditional management of breast abscesses involves incision and drainage of pus along with antistaphylococcal antibiotics, but this is associated with prolonged healing time, regular dressings, difficulty in breast feeding, and the possibility of milk fistula with unsatisfactory cosmetic outcome. It has recently been reported that breast abscesses can be treated by repeated needle aspirations and suction drainage. The predominance of Staphylococcus aureus allows a rational choice of antibiotic without having to wait for the results of bacteriological culture. Many antibiotics are secreted in milk, but penicillin, cephalosporins, and erythromycin, however, are considered safe. Where an abscess has formed, aspiration of the pus, preferably under ultrasound control, has now supplanted open surgery as the first line of treatment.     

CT-guided stereotactic aspiration of brain abscesses

The effective treatment of intracranial abscess remains controversial. Progress in technology, linked with the development of neuronavigational systems, has made stereotactic aspiration and drainage of intracerebral abscesses effective and valid alternatives to traditional methods, namely, conservative medical treatment or open surgical excision. Between 1995 and 2002, 12 patients at our hospital underwent drainage of intracerebral abscesses under stereotactic guidance. Ten patients had solitary lesions and two had multiple abscesses. The appropriate antibiotic schemes were administered following culture of the aspirated material. The size of the abscess, the mass effect, and response to antibiotic treatment were followed up by repeated CT scans. All patients showed improvement and, at the end of treatment, returned to their previous activities. There were neither deaths nor any postoperative complication. A second aspiration was required in one patient due to recurrence of the abscess. The CT-guided stereotactic aspiration of brain abscesses helps achieve all treatment goals. It drains the contents of the abscess, reduces mass effect, and confirms diagnosis. It is minimally invasive, carries minimal morbidity and mortality, and can be performed on compromised patients under local anesthesia.     

NON-OPERATIVE TREATMENT OF BREAST ABSCESSES

Background: Breast abscesses are conventionally treated by incision and drainage. This often requires general anaesthesia and a hospital stay. Non-operative treatment by needle aspiration and oral antibiotics is reported as a viable alternative. Methods: All patients who presented with breast abscesses and who were assessed by one surgeon between November 1995 and January 1997 were managed using a conservative approach and they are the subjects of this study. Results: Twenty-one consecutive patients were seen over a period of 26 months. All had non-lactational breast abscesses. Nineteen patients were successfully treated by needle aspiration and antibiotics while two patients required incision and drainage. The mean size of the aspirated abscesses was 3.5 cm (range 1–15 cm) and required an average of 2.4 aspirations (range 1–5). Of those treated by aspiration, three patients developed recurrent abscesses, two of which were successfully managed by repeat aspiration while one patient eventually required surgery. Conclusions: The majority of non-lactational breast abscesses seen in clinical practice can be treated without surgery by a combination of needle aspiration and antibiotics.     

Liver abscess: a clinicopathological analysis of 82 cases

Liver abscesses are a common pathology in India, but a strategy for effective treatment has not been established. Eighty-two patients with liver abscess were studied over a 4-year period. Clinical features, ultrasound findings, laboratory studies, and outcome of therapy were evaluated. Treatment options were antibiotics alone, needle aspiration, catheter drainage, or open surgical drainage; 51.2% of all abscesses were amebic, 23.2% were pyogenic, and 25.6% had unknown causes. A total of 75.6% of the abscesses were solitary, with 62.2% confined to the right lobe. Pyogenic abscesses were more likely to have anemia, leukocytosis, and deranged liver function. Amebic abscesses tended to have a larger volume. Patients undergoing catheter drainage showed a more rapid reduction in initial abscess volume, whereas resolution of the abscess cavity took longer with antibiotic therapy alone. Ultrasound-guided needle aspiration and catheter drainage are safe and effective in the management of liver abscess. Drug therapy alone may be useful only in select cases.     

A Retrospective Study of 75 Cases of Splenic Abscess

Splenic abscess is an uncommon and life-threatening condition. Due to its nonspecific clinical picture, it remains a diagnostic challenge. Multiple radiological modalities are used for the diagnosis. In this retrospective study we analyzed 75 patients treated between 1999 and 2009. The patients were divided into three groups depending on the treatment received. Group I (n = 14) consisted of patients treated with only antibiotics, Group II (n = 19) patients were treated with percutaneous drainage and Group III (n = 42) with splenectomy. We tried to establish epidemiologic and clinical features and therapeutic options in splenic abscess. Our study suggests that percutaneous drainage is a safe and effective alternative to surgery especially in unilocular or bilocular abscesses thus allowing preservation of the spleen. It should be considered as the first line of treatment although splenectomy remains the final definitive procedure if percutaneous drainage fails.     

Prostatic abscess caused by community‐acquired methicillin‐resistant Staphylococcus aureus

Prostatic abscess is uncommon and difficult to diagnose, because its clinical presentation mimics lower urinary tract symptoms. Prostatic abscess is often caused by gram‐negative organisms and occasionally by Staphylococcus aureus. Community‐acquired methicillin‐resistant S. aureus (MRSA) often causes skin and soft‐tissue infections, and rarely causes genitourinary infections. We report what we believe is the second case of a prostatic abscess as a result of MRSA in a healthy diabetic patient who was treated with transurethral resection of the prostate and intravenous administration of vancomycin.     

Current Treatment Strategies and Factors influencing Outcome in Patients with Bacterial Brain Abscess

Summary  We clearly determined the key to managing patients with brain abscess by retrospectively evaluating the factors affecting poor outcome in these patients. This study included 113 patients with brain abscess diagnosed in the CT era. Basic characteristics and therapeutic parameters were estimated as independent predictors of poor outcome by using univariate and multivariate logistic regression analysis. Patients with poor outcomes more frequently had deeply-located abscesses (p<0.02), IVROBA (intraventricular rupture of brain abscess) (p<0.001) and were in a severely deteriorated neurological state (p<0.001) than those with good outcomes. Multiple logistic regression analysis predicted that IVROBA (ORs, 24.5; 95% CI, 3.04 to 197.9) and severely deteriorated cases (ORs, 13.7; 95% CI, 2.34 to 80.8) resulting from IVROBA increased the relative risk of poor outcome. Patients with IVROBA more frequently had also deeply-located abscesses (p<0.005), positively immunocompromised states (p<0.05) an (p<0.003) than those without IVROBA. Patients with metastatic abscess had also IVROBA (p<0.006). Multiple logistic regression analysis anticipated that deeply-located abscess (ORs, 3.90; 95% CI, 1.38 to 11.04), and metastatic abscess (ORs, 12.26; 95% CI, 1.35 to 111.2) increased the relative risk of IVROBA. Patients in an obtunded state and with marked neurological deficit had IVROBA more often than patients in an alert state and/or mild neurological deficit (ORs, 3.23; 95% CI, 1.17 to 8.86, (p<0.03) before treatment. Our findings suggest that IVROBA strongly influences poor outcome in patients with brain abscess. The key to decreasing poor outcomes may be the prevention and management of IVROBA, by evaluating intracranial pressure pathophysiology. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with appropriate intravenous and intrathecial administration of antibiotics.     

Aspects of modern brain abscess diagnosis and treatment

Summary A clinical analysis of 115 patients with brain abscesses, who were operated in our department, provide valuable information about the diagnosis and treatment of such abscesses. Even in this antibiotic era the brain abscess has not lost its significance. The diagnosis of this lesion is one of the most difficult problems in neurology, and modern approaches with highly specialized instruments are therefore of especial importance; brain abscesses today are best detected by computer tomography. Various methods of treatment are described. The preferred procedure is a combined treatment consisting of puncture of the abscess, repeated aspiration of pus, instillation of a suitable antibiotic into the abscess cavity and complete removal of the abscess capsule at a later date. The importance of this treatment scheme is demonstrated by our own observations. Several unsolved problems including the prevention and treatment of rupture into the ventricle, the occurrence of multiple abscesses and the clinical treatment of fresh phlegmonous inflammations are discussed.

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Zusammenfassung Eine klinische Analyse unserer 115 operierten Hirnabszesse ergibt für die Diagnostik und Therapie der Abszesse wichtige Anhaltspunkte. Der Hirnabszeß hat auch in der antibiotischen Ära nicht an Bedeutung verloren. Seine Diagnose gehört zu den schwierigsten Kapiteln der Neurologie. Daher haben die modernen apparativen und instrumentellen Zusatzuntersuchungen um so größere Bedeutung. Die sicherste Methode zum Nachweis eines Hirnabszesses ist jedoch gegenwärtig die Computer Tomographie. Die verschiedenen Behandlungsverfahren werden dargestellt, wobei sich aber als die heute anzustrebende Therapie eine kombinierte Behandlung durch Punktion, mehrmalige Aspiration des Eiters, Einführen eines geeigneten Antibiotikums in die Abszeßhöhle und spätere Totalexstirpation des gesamten Narbengebietes erweist. Dies läßt sich auch anhand der eigenen Beobachtungen demonstrieren. Einige ungelöste Probleme — die Verhütung und Behandlung des Ventrikeleinbruchs, das Auftreten multipler Abszesse und das Vorgehen bei frischen, noch nicht eingeschmolzenen Entzündungen — werden besonders herausgestellt.

     

CT-guided stereotactic aspiration and treatment of brain abscesses

Summary The present study reports our experience with stereotactic puncture, aspiration and drainage of brain abscesses in 24 patients from a series of 34 consecutive cases. In all patients an intracavitary catheter was left in place for external drainage and daily irrigation with antibiotics. The patients received pre- and postoperatively triple broad spectrum antibiotic treatment, associated with low dose steroids and anti-epileptic drugs. Follow-up CT scans showed immediate reduction of the abscess size and gradual diameter diminution of the enhancing ring structure until its disappearance. The clinical presentation, risk factors, aetiology, outcome, bacteriological and CT findings were analysed. Mortality in this series was 4%. The majority of patients (96%) had no or minimal disability according to the Glasgow Outcome Scale. Our results confirm the value of this treatment policy and suggest that the stereotactic technique is a simple and safe method with minimal mortality and morbidity in the treatment of the majority of chronic brain abscesses.     

Nocardia brain abscess: severe CNS infection that needs aggressive management; case report

Summary  Nocardia brain abscess is a rare central nervous system (CNS) infection that carries a high mortality rate reaching 34% which is considered the highest amongst brain abscesses caused by microorganisms. All available literature is in the form of retrospective studies and small case series. In this case report the authors present a patient whose course of disease was stormy and required multiple neurosurgical procedures. The clinical outcome, long-term follow up and a review of the literature is discussed.     

Surgical treatment of cerebral abscess with the use of a mobile ultralow-field MRI

Surgical intervention in cerebral abscess is indicated to confirm diagnosis, to identify pathogens for specific antibiotic therapy, or to reduce mass effect. Regarding long-term outcome, freehand or stereotactic aspiration are equally efficient compared to surgical resection. However, direct observation of relief of mass effect is not possible by either method. Six patients presenting with neurological symptoms and laboratory signs of infection and diagnosed with an intra-axial cystic lesion underwent frameless stereotactic aspiration of a cerebral abscess in our institution with the use of a mobile intraoperative magnetic resonance imaging (MRI) with a field strength of 0.15 T. Images were acquired before and during the procedure and used for neuronavigation. In all six cases, complete evacuation of the abscess with collapse of the cyst could be achieved and documented intraoperatively. No complications were observed. All patients showed clinical improvement postoperatively. We highlight the advantages of using a mobile intraoperative MRI unit with an illustrative case of a patient who had already undergone abscess evacuation without alleviation of symptoms before using intraoperative MRI. Finally, we discuss surgical treatment options of cerebral abscesses.     

Primary melioidotic prostatic abscess: presentation,diagnosis and management

Introduction: In South‐East Asia and Northern Australia, melioidosis (infection with Burkholderia pseudomallei) is a known cause of severe community‐acquired sepsis. However, melioidosis presenting primarily as prostatic abscesses is very rare. Methods: The presenting features, investigations and management outcome of five patients who developed melioidotic prostatic abscesses from 1997 to 2000 were reviewed in the present study. Results: The mean age at presentation was 53 years (range: 29?69). Old age and diabetes mellitus were predisposing factors. All patients had a fever of at least 38.5°C and presented with obstructive urinary symptoms culminating in urinary retention. Presence of prostatic abscess was demonstrated by transrectal ultrasound in all cases. The abscesses were drained with transurethral resection of the prostate. One patient required re‐resection while another patient developed severe septic shock requiring intensive care and ­inotropic support. There was no mortality in our series. Conclusions: Elderly diabetic men presenting with fever and urinary tract obstruction in endemic areas may harbour an unusual but potentially life threatening melioidotic prostatic abscess. Transrectal ultrasound and bacteriological confirmation are mandatory. Prompt surgical drainage coupled with appropriate antibiotics are keys to a favourable outcome.     

Factors that enhance the likelihood of successful stereotactic treatment of brain abscesses

Summary Successful clinical outcomes are not achieved in all patients who undergo image-guided stereotactic surgery as the initial procedure in the management of brain abscess. We sought to define those factors related to management failure, so that the initial surgical approach could be selected using preoperative clinical or imaging criteria. We reviewed our twelve-year experience in 29 consecutive patients. Twenty-two (76%) patients had drainage of abscesses with purulent centers. Seven (24%) underwent lesion biopsy for diagnosis. Twelve patients (with abscesses >3 cm in average diameter) underwent stereotactic insertion of drainage catheters. Ten patients (34%) had adverse risk factors including immunologic suppression after prior organ transplantation, chronic steroid therapy, prior antineoplastic chemotherapy, or retained foreign body. Microbiological identification of the causative organism was obtained in 22 patients; 6 patients had positive Gram stains without growth in culture (bacteriological diagnosis=97%). Long-term clinical evaluation (up to 8.5 years, median 3 years) confirmed disease resolution after initial single-procedure stereotactic management in 21 patients (72%). Eventual abscess resolution occurred in an additional 6 patients (21%), all of whom required multiple procedures. Five patients died of complications of their systemic disease during the follow-up period. Fifteen of the 18 (83%) surviving patients who had no associated risk factors returned to their premorbid functional capacity. Factors associated with initial treatment failure included inadequate aspiration, lack of catheter drainage of larger abscesses, chronic immunosuppression, and insufficient antibiotic therapy.     

Renal and perirenal abscesses in patients with otherwise anatomically normal urinary tracts

PURPOSE: We characterized evaluation, management and outcomes in a group of patients diagnosed with renal and perirenal abscesses who had otherwise anatomically normal urinary tracts. MATERIALS AND METHODS: We reviewed our experience with renal/perirenal abscesses at University of Texas Medical Branch from 1991 to 2002. Treatment was determined by physician preference in each individual. RESULTS: Of 70 patients with renal/perirenal abscesses 26 had otherwise anatomically normal urinary tracts, 24 (92%) had at least 1 possible contributory factor, such as diabetes mellitus, and only 38% had the correct diagnosis at initial presentation. The abscess was intranephric in 39% of cases, intranephric and perinephric in 19%, and perinephric only in 42%. Of the 26 patients 18 were treated with percutaneous drainage or aspiration of the abscess and 12 (66.7%) had positive cultures. Eight of the 12 patients (67%) with positive abscess cultures had the same organism in urine and/or blood. All 26 patients were treated with broad-spectrum intravenous antibiotics. In most patients abscess size influenced additional treatments, such as percutaneous needle aspiration or catheter drainage. None of the patients required open surgical drainage, nephrectomy or nephrostomy tube placement. At a mean followup of 10 months all patients had complete radiographic resolution of the abscess without further complications except 1 who had pyelonephritis and another who was found to have a poorly perfused kidney. CONCLUSIONS: With accurate diagnosis and minimally invasive therapy patients with renal and/or perirenal abscesses and otherwise anatomically normal urinary tracts have excellent functional and anatomical outcomes.     

Successful Treatment of Renal Abscess with Percutaneous Needle Aspiration in a Diabetic Patient with End Stage Renal Disease Undergoing Hemodialysis

Renal abscesses in patients with end stage renal disease are quite rare, and misdiagnosis or delaying in diagnosis is frequent. This report examines a case of renal abscess in a patient with end stage renal disease on maintenance hemodialysis and diabetes mellitus, which presented with a prolonged fever. An infected diabetic foot was impressed initially. Purulent urine, pyuria, bacteriuria, and bacteremia were noted after admission. Renal abscess was diagnosed by percutaneous needle aspiration under computerized tomography guidance. The patient was treated with parenteral antibiotics and percutaneous aspiration of the abscess. Follow-up ultrasonography showed renal abscess resolution. This case demonstrated that nephrectomy was not required in selected uremic patients with renal abscess.