Original article

Best-practice care pathway for improving management of

mastitis and breast abscess
N. Patani1 , F. MacAskill1 , S. Eshelby1 , A. Omar1 , A. Kaura1 , K. Contractor1 , P. Thiruchelvam1,4 ,
S. Curtis2 , J. Main3 , D. Cunningham1 , K. Hogben1 , R. Al-Mufti1 , D. J. Hadjiminas1,4
and D. R. Leff1,4
1
Breast Unit, 2 Department of Microbiology and 3 Department of Infectious Diseases, Imperial College Healthcare NHS Trust, and 4 Department of
Surgery and Cancer, Imperial College, London, UK
Correspondence to: Mr D. R. Leff, Department of Surgery and Cancer, BioSurgery and Surgical Technology, 10th Floor, QEQM Wing, St Mary’s Hospital,
London W2 1NY, UK (e-mail: d.leff@imperial.ac.uk)

Background: Surgical subspecialization has resulted in mastitis and breast abscesses being managed
with unnecessary admission to hospital, prolonged inpatient stay, variable antibiotic prescribing, incision
and drainage rather than percutaneous aspiration, and loss to specialist follow-up. The objective was
to evaluate a best-practice algorithm with the aim of improving management of mastitis and breast
abscesses across a multisite NHS Trust. The focus was on uniformity of antibiotic prescribing, ultrasound
assessment, admission rates, length of hospital stay, intervention by aspiration or incision and drainage,
and specialist follow-up.
Methods: Management was initially evaluated in a retrospective cohort (phase I) and subsequently
compared with that in two prospective cohorts after introduction of a breast abscess and mastitis pathway.
One prospective cohort was analysed immediately after introduction of the pathway (phase II), and the
second was used to assess the sustainability of the quality improvements (phase III). The overall impact
of the pathway was assessed by comparing data from phase I with combined data from phases II and III;
results from phases II and III were compared to judge sustainability.
Results: Fifty-three patients were included in phase I, 61 in phase II and 80 in phase III. The
management pathway and referral pro forma improved compliance with antibiotic guidelines from 34 per
cent to 58⋅2 per cent overall (phases II and III) after implementation (P = 0⋅003). The improvement was
maintained between phases II and III (54 and 61 per cent respectively; P = 0⋅684). Ultrasound assessment
increased from 38 to 77⋅3 per cent overall (P < 0⋅001), in a sustained manner (75 and 79 per cent in phases
II and III respectively; P = 0⋅894). Reductions in rates of incision and drainage (from 8 to 0⋅7 per cent
overall; P = 0⋅007) were maintained (0 per cent in phase II versus 1 per cent in phase III; P = 0⋅381).
Specialist follow-up improved consistently from 43 to 95⋅7 per cent overall (P < 0⋅001), 92 per cent in
phase II and 99 per cent in phase III (P = 0⋅120). Rates of hospital admission and median length of stay
were not significantly reduced after implementation of the pathway.
Conclusion: A standardized approach to mastitis and breast abscess reduced undesirable practice
variation, with sustained improvements in process and patient outcomes.
Presented to a meeting of the Association of Breast Surgery, Manchester, UK, May 2016, and a meeting of the
Association of Breast Surgery, Birmingham, UK, June 2018; published in abstract form as Eur J Surg Oncol 2016;
42(Suppl 5), S4 and Eur J Surg Oncol 2018; 44(6): 862–863.

Paper accepted 7 May 2018

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10919

Introduction nipple trauma, which weakens the barrier function of the

Mastitis refers to inflammation of the breast, the aetiology
of which is most commonly infectious, but can occasionally
be granulomatous. Infection of the breast typically affects
lactating women and has been linked to milk stagnation and
skin and permits entry of bacteria1 . Non-lactating women
with other diagnoses such as duct ectasia can also develop
periductal mastitis. This has been associated with squa-
mous metaplasia impeding clearance, resulting in obstruc-
tive ductopathy2 . An abscess develops when the infected

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Published by John Wiley & Sons Ltd
 N. Patani, F. MacAskill, S. Eshelby, A. Omar, A. Kaura, K. Contractor et al.
tissue is localized and purulent material becomes walled off.
The pathogenesis most frequently involves bacterial infec-
tion following skin colonization with Staphylococcus aureus.
Less commonly, coagulase-negative staphylococci and/or
anaerobic organisms are isolated, particularly in smokers3 .
Lactational mastitis and periductal mastitis occur rela-
tively frequently, with reported rates of 5–10 per cent4 – 6 ,
and a similar proportion of these progress to abscess for-
mation. This amounts to a considerable disease burden
and healthcare costs4,5 . The magnitude of these remains
unknown, but will be informed by data from national qual-
ity improvement initiatives, such as the breast surgery work
stream Getting It Right First Time (GIRFT)7 .
Women with lactational or periductal mastitis, includ-
ing those with abscess, without systemic symptoms, skin
necrosis or immunocompromise, can be discharged safely
on appropriate oral antibiotics. An expedited outpatient
assessment in a breast clinic and image-guided interven-
tion where appropriate should follow1,8 – 11 . Admission to
hospital is best avoided in the postpartum period as it sep-
arates mother and baby unnecessarily. Simple analgesia
and systemic antibiotic therapy may be sufficient treatment
for uncomplicated mastitis. Early ultrasound-guided ther-
apeutic aspiration is recommended for abscesses to relieve
symptoms, effectively drain collections with minimal scar-
ring and breast deformation, and provide microbiology
samples to allow rationalization of empirical antibiotics.
Biopsies can also be taken for histology if granulomatous
inflammation or malignancy is suspected12 – 16 . Although
surgical incision and drainage represents the archetypal
treatment, in contemporary practice this is increasingly
reserved for situations in which image-guided aspiration is
not available within an appropriate time frame, has been
ineffective for large abscesses, or there is necrotizing infec-
tion requiring formal debridement4,17 – 20 . The Guidelines
and Audit Implementation Network21 and the National
Institute for Health and Care Excellence22 have published
recommendations for the management of breast abscess
and mastitis, which include the timing and choice of antibi-
otic therapy, use of ultrasound-guided needle aspiration,
and the need for specialist referral and follow-up.
Major barriers to optimal management of women with
mastitis include the potentially limited experience of
frontline healthcare providers owing to subspecialization,
inadequate access to interventional radiology, and inability
to access breast specialists out of hours. Despite published
guidelines4,21,22 , recent data suggest that many surgical
units in the UK do not have clear protocols for treating
breast infections referred to secondary care19 . The com-
bination of local organizational and logistical factors, in
addition to patients presenting acutely to non-specialists
© 2018 BJS Society Ltd
Published by John Wiley & Sons Ltd
out of hours, may result in undesirable practice variation,
suboptimal management and unnecessary healthcare
costs23 . Against this background, the objective of this work
was to evaluate practices in the management of breast
sepsis across a four-site hospital network; to develop a
best-practice care pathway algorithm for mastitis and
breast abscess; and, finally, to monitor pathway implemen-
tation and its impact on patient outcomes and key process
measures.
Methods
A retrospective audit (phase I) was undertaken between
January 2010 and December 2011 to evaluate the man-
agement of patients diagnosed with mastitis and/or breast
abscess presenting acutely to a multisite NHS Trust. The
Trust’s database was searched using the terms ‘mastitis’
and/or ‘breast abscess’, to capture patients presenting with
these diagnoses over a 2-year interval. Data were collected
by review of hospital records, focusing on the clerking case
notes, imaging, pathology and microbiology reports, phar-
macy records, and operation notes where applicable. The
key information included adherence to antibiotic guide-
lines, rates of hospital admission and length of inpatient
stay. Use of breast ultrasound imaging and intervention by
aspiration, frequency of operative incision and drainage,
involvement of breast surgeons and rates of specialist breast
surgical follow-up were also monitored. Data were col-
lected using standard templates and entered into a secure
electronic database. The audit was registered with the Trust
(identifier 047529) and the staged results presented at clin-
ical governance meetings.
Development of mastitis and breast abscess
protocol
After evaluation of existing processes and key outcome
measures for patients presenting with mastitis and/or
breast abscess, a referral pro forma and best-practice
management algorithm were developed. This involved
consultation with surgeons, radiologists, microbiologists
and emergency physicians, using the Delphi method to
reach consensus24 . The subject was ratified by the hospitals
antibiotic review group, and the Trust’s quality and safety
review board. Local ethics committee approval was not
required for this process. The resulting breast abscess and
mastitis pathway (Fig. 1) was thereafter introduced across
the multisite NHS Trust in 2014.
The purpose of the management algorithm was to
equip non-specialists with an evidence-based decision tool
regarding the clinical indications for hospital admission
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Management of mastitis and breast abscess
Breast pain/erythema/swelling/discharge
Clinically well
Clinically apparent abscess
Yes No
Drain
Consider drainge +/– ultrasound
guidance by surgical SpR or ED consultant
Send aspirate for microscopy, culture and sensitivity
Consider EMLA cream before aspiration
Further management
Analgesia: paracetamol, ibuprofen
Antibiotics
First line: oral co-amoxiclav 625 mg TDS for 10–14 days
Second line/penicillin allergy/non-lactational mastitis: oral
clindamycin 300 mg QDS for 10–14 days
If breastfeeding, MRSA-positive or fungal, consult
microbiology
Lactational mastitis: encourage patient to ‘express breast,
heat and rest’
Discharge home: clinically well patients do not require
admission
Fig. 1Breast abscess and mastitis pathway. HIV, human immunodeficiency virus; WCC, white cell count; SpR, specialist registrar; ED,
emergency department; TDS, three times daily; QDS, four times daily; MRSA, methicillin-resistant Staphylococcus aureus; BD, twice
daily
and Trust antibiotic guidelines to minimize practice vari-
ation. Patients could be triaged effectively, appropriate
initial treatment started, and breast specialists alerted by
completion of the referral pro forma (Fig. S1, supporting
information). The completed pro formas were faxed to
the breast services booking office, centralized at one of
the hospitals. Patients were then contacted to arrange an
appointment with a breast surgeon and to undergo special-
ist ultrasound assessment with aspiration if appropriate,
typically on the next working day.
The management pathway was uploaded on to the Trust’s
intranet and the referral pro forma was made available
online across four teaching hospitals of the Trust. At each
site, education and training sessions were undertaken to
ensure that relevant accident and emergency staff, general
surgery teams and the breast unit administrative team
had familiarized themselves with the best-practice pathway
and were notified of critical changes in practice. Pathway
education and training sessions were repeated on several
© 2018 BJS Society Ltd
Published by John Wiley & Sons Ltd
Clinically unwell?
Severe infection/sepsis (tachycardia, temperature > 38°C,
respiratory rate >20 per min)
or immunocompromised (steroids, HIV, chemotherapy,
low WCC)
or adverse local signs (spreading erythema, necrotizing
fasciitis)
or poor response to oral antibiotics
Admit for treatment
Inform
In hours: breast SpR
Out of hours: general SpR
Investigations
Bloods tests including blood cultures
Breast ultrasound imaging if abscess suspected
Further management
Analgesia: paracetamol, ibuprofen
Antibiotics: i.v. ≥ 3 days, then oral. Total course 14 days
First line: i.v. co-amoxiclav 1.2 g TDS
Penicillin allergy: i.v. clindamycin 600–1200 mg QDS
Second line/MRSA-positive: i.v. vancomycin 1 g BD
If breastfeeding, MRSA-positive or fungal, consult
microbiology
Incision and drainage for
Abscess with failed needle aspiration
Skin necrosis
occasions to account for rotating junior trainees in breast
surgery, general surgery and emergency departments, and
repeated again before further audit phases.
Further audit of pathway implementation
A loop-closing audit25 was conducted between January
2015 and February 2016 to reassess practice and determine
improvements in the quality of care. The prospective audit
comprised two consecutive time intervals (Fig. 2); the first
(phase II) was undertaken between January 2015 and July
2015, and the second (phase III) between August 2015 and
February 2016. Data were collected from all four centres
for patients with mastitis and/or breast abscess referred to
either the on-call surgical team or breast services. On a
daily basis, all general surgical admissions from the pre-
ceding day were screened to identify women admitted
with mastitis and breast abscess. Accident and emergency
records were also reviewed to identify patients diagnosed
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Pathway
introduction
2014
Phase I
Retrospective audit
Jan 2010 to Dec 2011
n = 53
Before pathway introduction
Improvement
Fig. 2 Study design and analytical strategy
with mastitis and/or breast abscess who were discharged
pending outpatient review; and uptake of the pro forma was
recorded. Pro formas faxed to the breast unit were similarly
reviewed, and cross-referenced against accident and emer-
gency (outpatient managed) and general surgical (inpa-
tient managed) records. The following data were collected:
uptake of the pro forma, rates of hospital admission, com-
pliance with antibiotic policy, use of ultrasound assessment,
frequency of interventions such as percutaneous aspiration
and surgical drainage, and rates of specialist follow-up after
the acute phase. Data were collected as described for the
retrospective audit.
Statistical analysis
Data from each phase of the study were analysed across
five key domains: compliance with antibiotic guidelines;
ultrasound assessment and aspiration rates; hospital admis-
sion and length of stay; operative incision and drainage
rates; and specialist follow-up. The retrospective audit data
collected before instigation of the pathway (phase I) were
compared with combined data from the two prospective
audit cycles (phases II and III). Further comparisons were
undertaken to determine when the improvement occurred
(phase I versus II and phase I versus III). To determine
whether improvements in practice were sustained, direct
comparisons were made between the two prospective audits
(phase II versus III) (Fig. 2). Unavailable data were assumed
to reflect non-compliance with the management pathway
and/or Trust guidelines. Outcome measures, such as rates
of antibiotic use, hospital admission, operative incision and
© 2018 BJS Society Ltd
Published by John Wiley & Sons Ltd
N. Patani, F. MacAskill, S. Eshelby, A. Omar, A. Kaura, K. Contractor et al.
Education and
staff engagement
Phase II Phase III
Prospective audit Prospective audit
Jan 2015 to Jul 2015 Aug 2015 to Feb 2016
n = 61 n = 80
Sustained
improvement
After pathway introduction
drainage, and specialist follow-up, were expressed as fre-
quencies and analysed using the χ2 test. Duration of hos-
pital stay, presented as median (range), was analysed using
the Mann–Whitney U test. For all analyses, P < 0⋅050 was
deemed statistically significant. Analyses were conducted
using SPSS® version 24 (IBM, Armonk, New York, USA).
Results
Fifty-three patients were included in phase I, before imple-
mentation of the breast abscess and mastitis pathway, and
61 and 80 patients in phases II and III respectively, after
introduction of the pathway.
Antibiotic compliance
Overall compliance with the antibiotic prescribing pol-
icy improved significantly following pathway implemen-
tation from 34 per cent (18 of 53) to 58⋅2 per cent (82
of 141) (P = 0⋅003). Unavailable data (10 patients before
and 26 after introduction of the pathway) were assumed
to reflect non-compliance. After pathway implementation,
there was greater uniformity and a reduction in the range of
antibiotics prescribed (Fig. 3; Table S1 and Fig. S2, support-
ing information). Improvements in practice were evident
in both prospective cohorts: 34 per cent in phase I versus
54 per cent in phase II (P = 0⋅049) and 61 per cent in phase
III (P = 0⋅003). Compliance with antibiotic guidelines was
maintained (phase II versus III; P = 0⋅684).
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Management of mastitis and breast abscess

80 Other antibiotic combinations incision and drainage was maintained following pathway
Co-amoxiclav implementation (phase II versus III; P = 0⋅381).
Not prescribed or unknown

60 Hospital admission and length of stay

Rates of hospital admission were reduced from 30 per cent
No. of patients

(16 of 53) to 20⋅6 per cent (29 of 141) following pathway

40
20
0
Phase I Phase II Phase III
Before pathway After pathway introduction
introduction
Fig. 3Impact of best-practice management pathway on antibiotic
prescribing. Number of patients receiving first-line antibiotic
(co-amoxiclav), other antibiotics and where antibiotic
prescriptions were unknown or no antibiotics prescribed
Ultrasound assessment
The assessment of women with mastitis and/or breast
abscess using ultrasound imaging was markedly increased
overall following pathway implementation from 38 per
cent (20 of 53) to 77⋅3 per cent (109 of 141) (P < 0⋅001),
and maintained between phase II and phase III (75 per
cent (46 of 61) versus 79 per cent (63 of 80) respectively;
P = 0⋅894). Unavailable data were assumed to reflect lack
of imaging (phase I, 13 patients; phase II, 9; phase III, 10).
implementation, although this did not reach statistical
significance (P = 0⋅247). There were no significant differ-
ences in rates of admission between any of the phases (30
per cent in phase II and 14 per cent in phase III) (Table S1,
supporting information). When patients with unknown
admission status were excluded from the analysis, a statis-
tically significant reduction in admission rate was observed
in phase III (P = 0⋅018 versus phase I; P = 0⋅027 versus
phase II). Similarly, there was no change in median length
of hospital stay for patients admitted following pathway
adoption: 2 (range 1–5) and 1 (1–6) days in phases I and
II–III respectively (P = 0⋅079).
Follow-up
Rates of follow-up with breast specialists were substantially
improved after pathway implementation, from 43 per cent
(23 of 53) to 95⋅7 per cent (135 of 141) (P < 0⋅001) (Fig. 4).
Significant improvement was demonstrated both in phase
II (92 versus 43 per cent in phase I; P < 0⋅001) and phase III
80 No follow-up
Specialist
Unknown

60
Aspiration versus surgical drainage
No. of patients

The greater use of ultrasound assessment after intro-

duction of the pathway provided an opportunity for
image-guided intervention when appropriate, but rates 40

of aspiration did not change significantly: 23 per cent (12

of 53) in phase I, 25 per cent (15 of 61) in phase II and
21 per cent (15 of 80) in phase III (Table S1, supporting
information). 20
Although similar proportions of patients underwent
aspiration, the overall rate of surgical incision and drainage
under general anaesthesia was significantly reduced fol-
lowing pathway implementation from 8 per cent (4 of 53) 0
Phase I Phase II Phase III
to 0⋅7 per cent (1 of 141) (P = 0⋅007). This improvement
Before pathway After pathway introduction
was significant in phase II (0 per cent versus 8 per cent in introduction
phase I; P = 0⋅029), but not in phase III (1 per cent versus
8 per cent in phase I; P = 0⋅062). Attenuation in rates of Fig. 4 Impact of best-practice management pathway on follow-up

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 N. Patani, F. MacAskill, S. Eshelby, A. Omar, A. Kaura, K. Contractor et al.
(99 versus 43 per cent in phase I; P < 0⋅001). The improve-
ment was sustained (phase II versus III; P = 0⋅120). This
was attributable to a reduction in the number of women
who received no follow-up, were lost to follow-up or with
unknown follow-up status (Fig. 4; Table S1, supporting
information).
Discussion
The objective of the pathway was to improve the man-
agement of patients presenting with mastitis and/or breast
abscess to a multisite hospital NHS Trust. A retrospective
audit identified significant practice variation and subopti-
mal management, leading to inappropriate antibiotic pre-
scriptions and unnecessary hospital admissions. Rates of
ultrasound assessment were low, and rates of operative inci-
sion and drainage were high, with inadequate involvement
of breast specialists and inconsistent follow-up.
Prompt management and early intervention for masti-
tis and/or breast abscess has important implications for
patient outcome. Refractory or recurrent infection may be
associated with delayed diagnosis, suboptimal treatment,
and contributory patient factors such as poor breastfeed-
ing technique, diabetes and smoking26 – 28 . Although there
were no patients with inflammatory breast cancer in this
study, failing to involve breast specialists and to consider
this important diagnosis can have profound clinical and
medicolegal implications29 .
One of the key barriers to optimal management is the fre-
quent presentation of patients to non-specialist emergency
services out of hours. Non-specialists did not report any
significant issues in following the management pathway
and referral pro forma, and dissemination was facilitated
by the Trust’s intranet. The standardized approach to
managing women with mastitis and/or breast abscess led
to measurable and non-transient improvements in key
process and outcome measures.
It is noteworthy that the improvement in some key per-
formance indicators, such as reduction in hospital admis-
sion rates, did not occur until phase III of the study. This
reflects the importance of ongoing education and train-
ing sessions even after phase II implementation, in order
to hardwire best practice30 . It also highlights the need
to maintain staff engagement with quality improvement
initiatives31 . The fact that pathway training was repeated
before further practice audit may account for the positive
impact in eventually curtailing admission rates. Notwith-
standing this, the uptake of pro forma use for referrals
was found to vary across hospital sites and during the
course of the audit. The management of change, partic-
ularly protocol awareness and compliance, represents an
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important issue for the sustainability of quality improve-
ment endeavours.
The high turnover of frontline staff in emergency
services, general surgery and the breast unit itself
poses a threat to securing sustainability after the ini-
tial intervention30,32 – 35 . Change leaders need to engage
with new practitioners for targeted education and training.
This is both labour-intensive and impractical. Ideally,
innovative strategies should be sought to facilitate rapid
familiarization of incoming staff with best-practice clinical
pathways. These include system-based opportunities, such
as introducing standardized online induction modules
for new employees24 , linking breast-specific clerking pro
formas to the best-practice pathway using the electronic
patient record36,37 , facilitating direct peer-to-peer han-
dover of conditions for which integrated management
pathways exist38 , and reinforcing mechanisms to provide
positive feedback and discourage non-compliant practice34 .
Although the present data support a considerable reduc-
tion in hospital admission rates and length of stay follow-
ing pathway implementation, these changes did not reach
statistical significance. The observed reduction in hospi-
tal admission rates from 30 per cent in phase I to 14 per
cent in phase III following pathway introduction is mean-
ingful, but the appropriateness of an admission rate of 14
per cent for mastitis still has to be questioned. Future ini-
tiatives to curtail hospital admission rates for mastitis and
breast abscess may also couple pathway implementation to
an independent case review.
In addition to the integrated management pathway
improving key process measures and patient outcomes,
there are potentially significant cost benefits of getting
management ‘right first time’7 . Such changes have down-
stream consequences, and an impact assessment would
highlight the additional cost of outpatient appointments,
specialist ultrasound assessments and image-guided aspira-
tions. Interestingly, although access to ultrasound imaging
improved, the aspiration rate did not change significantly.
The reasons for this are probably multifactorial, perhaps
indicating the availability of staff with appropriate skills
in image-guided aspirations, or more likely reflecting the
relative proportions of inflammatory change (mastitis)
versus collection (abscess) observed sonographically. The
latter may reflect scans being undertaken earlier in the
natural history of mastitis before abscess development.
Limitations of this study include the retrospective nature
of the initial audit, which may have failed to capture
the total number of episodes and details of treatment.
Although every effort was made to ensure that all women
with mastitis and/or breast abscess were included dur-
ing the study phases, patients in whom the pro forma
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Management of mastitis and breast abscess
and pathway were not used may have been missed and
the true denominator therefore remains unknown. Patient
demographic data were not collected to determine the
distribution of key confounding variables such as breast-
feeding, smoking or diabetes. The number of patients
included in this study was modest and the unpredictable
nature of mastitis/abscess presentation made it challenging
to ensure parity in the number of patients between each
phase of the study. The sample size may also have con-
tributed to the observation of clinically important improve-
ments that failed to reach statistical significance (type II
error with false-negative findings) such as hospital admis-
sion rates and length of inpatient stay.
An integrated care pathway and referral pro forma, along
with ongoing education and training of staff, achieved sig-
nificant and sustained improvements in the management
of patients with mastitis and/or breast abscess presenting
to this NHS Trust. These quality improvements may be
generalizable to other acute Trusts with similar organi-
zational structures. Future work will explore options for
national-level engagement on breast sepsis through collab-
orations with the breast surgery work stream of the GIRFT
quality improvement initiative7 .
Acknowledgements
This study was funded by the Breast Unit, Imperial College
Healthcare NHS Trust and Imperial National Institute for
Health Research Biomedical Research Centre.
Disclosure: The authors declare no conflict of interest.
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