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ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 213-216

A study on microbiological profile and risk factors of breast abscess cases attending a tertiary care hospital in Kolkata


1 Department of Microbiology, R. G. Kar Medical College, Kolkata, West Bengal, India
2 Department of Microbiology, IPGMER, Kolkata, West Bengal, India

Date of Web Publication15-Oct-2018

Correspondence Address:
Dr. Maitreyi Bandyopadhyay
Department of Microbiology, R. G. Kar Medical College and Hospital, Kolkata - 700 004, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_150_17

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  Abstract 


INTRODUCTION: Primary breast abscesses occur both in the puerperal and nonpuerperal settings and affect women of all ages. Breast abscesses are a common complication of the postpartum period afflicting 9%–33% of all lactating women. Incision and drainage with postoperative antibiotic drugs has been suggested as the treatment of choice but data regarding the bacteriological profile and antibiotic susceptibility is lacking.
AIMS AND OBJECTIVES: To find out the risk factors, bacteriological profile along with antibiotic susceptibility pattern of breast abscess cases.
MATERIALS AND METHODS: A total of 136 breast abscess cases were studied over a period of 1 year to identify the risk factors and to isolate the organisms.
RESULTS: Among 136 cases 88 (64.7%) were suffering from puerperal breast abscess whereas 48 (35.3%) patients suffered from nonpuerperal breast abscess. Staphylococcus aureus was the predominant pathogen, of which 57.35% showed methicillin resistance. Young age, primiparous, difficulty in lactation came out to be the most important risk factors for development of puerperal breast abscess whereas diabetes mellitus was the predominant risk factor for nonpuerperal breast abscess.
DISCUSSION: This is the first study from India in recent past to evaluate the susceptibility patterns of bacterial isolates from breast abscesses as well as risk factors for development of breast abscesses which highlights probably the emergence of community-acquired methicillin-resistant S. aureus as a predominant pathogen of breast abscess cases.

Keywords: Bacteriological profile, breast abscess, community-acquired methicillin-resistant Staphylococcus aureus


How to cite this article:
Kumar S, Bandyopadhyay M, Debnandi A, Sengupta A, Bandyopadhyay MK, Mukhopadhyay PK, Chatterjee M. A study on microbiological profile and risk factors of breast abscess cases attending a tertiary care hospital in Kolkata. Int J Health Allied Sci 2018;7:213-6

How to cite this URL:
Kumar S, Bandyopadhyay M, Debnandi A, Sengupta A, Bandyopadhyay MK, Mukhopadhyay PK, Chatterjee M. A study on microbiological profile and risk factors of breast abscess cases attending a tertiary care hospital in Kolkata. Int J Health Allied Sci [serial online] 2018 [cited 2018 Dec 9];7:213-6. Available from: http://www.ijhas.in/text.asp?2018/7/4/213/243263




  Introduction Top


Primary breast abscesses occur both in the puerperal and nonpuerperal settings and affect women of all ages. Breast abscesses are a common complication of the postpartum period afflicting 9%–33% of all lactating women.[1],[2],[3],[4],[5] Nonpuerperal breast abscesses also remain a significant disease owing to their underlying disability and incidence of recurrence. Incision and drainage with postoperative antibiotic drugs has been suggested as the treatment of choice for these abscesses based on their pathogenesis.[6] However, recent studies[7],[8],[9],[10] have suggested that ultrasound-guided aspiration plus systemic antibiotic drug therapy may be less invasive, with an improved cosmetic outcome and a higher cure rate. Whereas the best drainage modality for the treatment of breast abscesses is being extensively studied, the bacteriologic features of postpartum and nonpuerperal breast abscesses has not been systematically evaluated in India. To increase the success rate of minimally invasive drainage techniques with adjunctive antimicrobial drug therapy, knowledge of the microbiologic spectrum of breast abscesses as well as their antimicrobial susceptibility is necessary. There are few data on the risk factors associated with primary breast abscess. Risk factors for postpartum breast abscesses are also poorly defined, and literature is conflicting. In recent past there have been no previous studies from India, regarding the bacteriological profile and risk factors associated with breast abscess, so this study was undertaken to analyze the risk factors associated with development of primary breast abscess and the bacteriological profile and in vitro antimicrobial susceptibility pattern of the causative organisms.

Aims and objectives

To find out the risk factors, bacteriological profile along with antibiotic susceptibility pattern of breast abscess cases.


  Materials and Methods Top


All female patients with breast abscess who underwent treatment in the period between March 2013 to February 2014 were included in the study. It was a prospective observational study. Risk factors for development of breast abscess like young age, low parity, lactation, difficulty in lactation (presence of cleft lip/palate), use of breast pumps, use of tobacco, underlying diabetes mellitus, obesity (body mass index >30) were assessed by questionnaire method. Infant information regarding gestational age, birthweight, and neonatal intensive care unit admission status, were obtained. Informed consent was obtained from the patients.

After incision and drainage of breast abscesses, pus samples were immediately sent to the microbiology laboratory in a sterile test tube. All specimens were examined by Gram-stained smears, potassium hydroxide (KOH) mount and Ziehl Neelsen stain, followed by inoculation onto blood agar and MacConkey agar plates which were incubated aerobically at 37°C for 24 h, which was extended to 48 h if there was no growth. The chocolate agar was incubated in air plus 10% CO2 for 24 h.[11] Isolated organisms were identified following standard laboratory protocols by phenotypic methods. All isolates were subjected to antimicrobial susceptibility testing by modified Kirby Bauer Disc Diffusion method as per Clinical and Laboratory Standards Institute guidelines.[12] Methicillin resistance were detected using cefoxitin (30 μg) disk on Mueller Hinton agar plates.

Statistical calculations were done using appropriate software.


  Results Top


During the study period total 136 cases of breast abscess who underwent incision and drainage at our institute were included. Among 136 cases 88 (64.7%) were suffering from puerperal breast abscess whereas 48 (35.3%) patients suffered from nonpuerperal breast abscess i.e., 88 patients were lactating and 48 patients were nonlactating. All pus samples showed monomicrobial bacterial yield. Total 136 pathogens were isolated from 136 pus samples. Staphylococcus aureus was the predominant pathogen. None of the samples showed presence of any acid-fast bacilli or any fungal element in the primary staining. The overall species distribution is shown in the [Table 1].
Table 1: Species distribution of organisms causing breast abscess

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Methicillin resistance was noted in all the isolates. Most of the isolates (57.35% of the total isolates) showed methicillin resistance. All the isolates of Staphylococcus lugdunensis and Staphylococcus schleiferi showed methicillin resistance [Table 1].

The antimicrobial susceptibility pattern of S. aureus is shown in [Table 2]. S. aureus isolates were susceptible to the major drugs used in the management of breast abscesses. Inducible clindamycin resistance was tested in all the isolates. All methicillinresistant S. aureus (MRSA) isolates were susceptible to Vancomycin, Linezolid and most isolates (91.4%) were susceptible to trimethoprim-sulfamethoxazole but 11 (17.2%) MRSA isolates showed resistance to clindamycin and erythromycin. Antimicrobial susceptibility patterns of the MRSA isolates in this study are typical of community-associated MRSA (high susceptibility to non beta lactam antibiotics) similar to that of recent reports.
Table 2: Antimicrobial susceptibility pattern of Staphylococcus species from breast abscess

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Risk factors for development of breast abscess were assessed by questionnaire method. Young age, primiparous, difficulty in lactation came out to be the most important risk factors for development of puerperal breast abscess whereas diabetes mellitus was the predominant risk factor for nonpuerperal breast abscess. Infants of two mothers had cleft palate and use of breast pumps by 4 patients were a major finding. Risk factors are shown in [Table 3].
Table 3: Risk factors associated with breast abscess

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  Discussion Top


In the recent past no studies have been published from India about the microbiologic features and risk factors of breast abscesses. This is the first study from India in recent past to evaluate the susceptibility patterns of bacterial isolates from breast abscesses as well as risk factors for development of breast abscesses.

Our study found that S aureus is the most common aerobic organism, found in 91.2% (62 out of 68) of cultures, with more than half (57.35%) of these isolates being MRSA. This high prevalence of MRSA is similar to the to the reports of high prevalence reported for other skin and soft tissue infections in other countries.[13],[14],[15] Clindamycin and cotrimoxazole were the oral antibiotics found to be effective against most of the S. aureus strains. Antimicrobial susceptibility patterns of the MRSA isolates in this study are typical of community-associated MRSA with most isolates showing a high in vitro susceptibility to many antibiotics as indicated in other recent reports.[16],[17] For decades MRSA was a nosocomial pathogen seen predominantly in hospitalized patients. Recently it has caused infections in patients, including those without risk factors. This study highlights the emergence of MRSA in the community with regards to breast abscess cases. High incidence of MRSA suggests a reservoir of MRSA in the community, posing threats for their children and family in large. There are also reports that suggests that MW2, a community-acquired strain, may become a health care–associated pathogen. This is particularly worrisome, given the short mean LOS among the case patients and the high rate of readmission to several hospitals.[18]

Because of the emergence of MRSA as a causative agent of breast abscess in this population (possibly resulting from the increase in community-acquired methicillin-resistant S. aureus [CA-MRSA]), failure of empirical β-lactam therapy for early breast abscess should prompt consideration of treatment with an agent active against MRSA. In our study, both clindamycin and trimethoprim-sulfamethoxazole were potentially useful oral antibiotic agents which is similar to the finding by Mitrano et al.[19] The decreased susceptibility of clindamycin due to inducible clindamycin resistance as indicated in this study also highlights the decreasing oral options for treatment for breast abscess cases. Susceptibility profiles for CA-MRSA often vary by region, highlighting the importance of performing cultures for antimicrobial susceptibility testing in this population.

In our study period we found that the incidence of lactational or puerperal breast abscess is higher than nonpuerperal breast abscess. Among the lactating patients we found that young age of patients, primiparity and difficulty in lactation were major risk factors for development of lactational breast abscess. This may be attributed to inexperience and difficulty in breastfeeding among primi mothers resulting in cracked nipples or fissures which may develop into breast abscess later. Among the nonpuerperal breast abscess cases diabetes mellitus was a major risk factor. We did not find any significant association of development of breast abscess with smoking/tobacco use and obesity.

With increasing emergence of MRSA and more minimally invasive management of breast abscesses, understanding the current bacteriologic profile with antibiotic susceptibility pattern of these abscesses is essential to determining the correct empirical antibiotic drug therapy. Understanding the risk factors associated with development of breast abscesses is also important to take necessary preventive measures.

This study also highlights the importance of Coagulase negative staphylococcus as potential agents of breast abscesses, indicated by the S. lugdunensis and S. schleiferi isolates obtained in the study.[20]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bharat A, Gao F, Aft RL, Gillanders WE, Eberlein TJ, Margenthaler JA, et al. Predictors of primary breast abscesses and recurrence. World J Surg 2009;33:2582-6.  Back to cited text no. 1
    
2.
Amir LH, Forster D, McLachlan H, Lumley J. Incidence of breast abscess in lactating women: Report from an Australian cohort. BJOG 2004;111:1378-81.  Back to cited text no. 2
    
3.
Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: Occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol 2002;155:103-14.  Back to cited text no. 3
    
4.
Chuwa EW, Wong CM, Tan YY, Hong GS. MRSA breast abscesses in postpartum women. Asian J Surg 2009;32:55-8.  Back to cited text no. 4
    
5.
Eryilmaz R, Sahin M, Hakan Tekelioglu M, Daldal E. Management of lactational breast abscesses. Breast 2005;14:375-9.  Back to cited text no. 5
    
6.
Kinlay JR, O'Connell DL, Kinlay S. Incidence of mastitis in breastfeeding women during the six months after delivery: A prospective cohort study. Med J Aust 1998;169:310-2.  Back to cited text no. 6
    
7.
Moazzez A, Kelso RL, Towfigh S, Sohn H, Berne TV, Mason RJ, et al. Breast abscess bacteriologic features in the era of community-acquired methicillin-resistant Staphylococcus aureus epidemics. Arch Surg 2007;142:881-4.  Back to cited text no. 7
    
8.
Christensen AF, Al-Suliman N, Nielsen KR, Vejborg I, Severinsen N, Christensen H, et al. Ultrasound-guided drainage of breast abscesses: Results in 151 patients. Br J Radiol 2005;78:186-8.  Back to cited text no. 8
    
9.
Thirumalaikumar S, Kommu S. Best evidence topic reports. Aspiration of breast abscesses. Emerg Med J 2004;21:333-4.  Back to cited text no. 9
    
10.
Berna-Serna JD, Madrigal M, Berna-Serna JD. Percutaneous management of breast abscesses. An experience of 39 cases. Ultrasound Med Biol 2004;30:1-6.  Back to cited text no. 10
    
11.
Kloos WE, Banerman TL. Staphylococcus and Micrococcus. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolken RH, editors. Manual of Clinical Microbiology. 7th ed., Ch. 22. Washington, DC: ASM Press; 1999. p. 264-82.  Back to cited text no. 11
    
12.
Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Seventeenth Informational Supplement. Vol. 27. Clinical Laboratory Standards Institute; 2007.  Back to cited text no. 12
    
13.
Chambers HF. The changing epidemiology of Staphylococcus aureus? Emerg Infect Dis 2001;7:178-82.  Back to cited text no. 13
    
14.
Eady EA, Cove JH. Staphylococcal resistance revisited: Community-acquired methicillin resistant Staphylococcus aureus – An emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 2003;16:103-24.  Back to cited text no. 14
    
15.
Ala'Aldeen D. A non-multiresistant community MRSA exposes its genome. Lancet 2002;359:1791-2.  Back to cited text no. 15
    
16.
Adhikari RP, Cook GM, Lamont I, Lang S, Heffernan H, Smith JM, et al. Phenotypic and molecular characterization of community occurring, Western Samoan phage pattern methicillin-resistant Staphylococcus aureus. J Antimicrob Chemother 2002;50:825-31.  Back to cited text no. 16
    
17.
Almer LS, Shortridge VD, Nilius AM, Beyer JM, Soni NB, Bui MH, et al. Antimicrobial susceptibility and molecular characterization of community-acquired methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis 2002;43:225-32.  Back to cited text no. 17
    
18.
Saiman L, O'Keefe M, Graham PL 3rd, Wu F, Saïd-Salim B, Kreiswirth B, et al. Hospital transmission of community-acquired methicillin-resistant Staphylococcus aureus among postpartum women. Clin Infect Dis 2003;37:1313-9.  Back to cited text no. 18
    
19.
Mitrano JA, Spooner LM, Belliveau P. Excretion of antimicrobials used to treat methicillin-resistant Staphylococcus aureus infections during lactation: Safety in breastfeeding infants. Pharmacotherapy 2009;29:1103-9.  Back to cited text no. 19
    
20.
Asnis DS, St John S, Tickoo R, Arora A. Staphylococcus lugdunensis breast abscess: Is it real? Clin Infect Dis 2003;36:1348.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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