What are the diagnostic criteria and treatment options for moderate vs severe mastitis?

From the Guidelines

Mastitis is diagnosed based on clinical presentation, with moderate mastitis characterized by localized breast pain, redness, swelling, and flu-like symptoms including fever (usually <101.3°F or 38.5°C), while severe mastitis presents with more intense symptoms, higher fever (>101.3°F), extensive breast inflammation, and possibly abscess formation. The diagnostic criteria for mastitis include clinical examination revealing erythema occupying at least one-third of the breast, and a history of no more than 6 months 1. For moderate mastitis, treatment includes:

• Continued breastfeeding or milk expression from the affected breast
• Adequate rest and hydration
• Anti-inflammatory medications like ibuprofen (400-600mg every 6-8 hours)
• Antibiotics such as dicloxacillin or cephalexin (500mg four times daily for 10-14 days) Severe mastitis requires more aggressive management with:
• Broader-spectrum antibiotics like amoxicillin-clavulanate (875/125mg twice daily for 10-14 days) or clindamycin (300mg four times daily) if MRSA is suspected
• Possible hospitalization for IV antibiotics
• Ultrasound evaluation to rule out abscess formation
• Surgical drainage if an abscess is present Both conditions require continued breast emptying as the cornerstone of treatment, as milk stasis worsens inflammation and infection 1. Prompt treatment is essential to prevent complications like abscess formation or sepsis, particularly in severe cases. If symptoms don't improve within 48 hours of antibiotic therapy, reevaluation is necessary to consider resistant organisms or abscess development. It's worth noting that mastitis is different from inflammatory breast cancer, which has distinct clinical features, including erythema and dermal edema (peau d’orange) of a third or more of the skin of the breast with a palpable border to the erythema 1.

From the Research

Diagnostic Criteria for Moderate and Severe Mastitis

• The diagnosis of mastitis is usually clinical, with patients presenting with focal tenderness in one breast accompanied by fever and malaise 2.
• Symptoms such as fever, malaise, focal breast tenderness, and overlying skin erythema or hyperpigmentation are used to diagnose mastitis 3.
• Moderate mastitis may be characterized by the presence of these symptoms without significant complications, while severe mastitis may involve more serious complications such as abscesses or sepsis.

Treatment Options for Moderate and Severe Mastitis

• Treatment for moderate mastitis often includes conservative measures such as nonsteroidal anti-inflammatory drugs, ice application, and continued breastfeeding 3.
• If there is no improvement in symptoms, narrow-spectrum antibiotics may be prescribed to cover common skin flora (e.g., Staphylococcus, Streptococcus) 3.
• Severe mastitis may require more aggressive treatment, including intravenous antibiotics and hospital admission, especially if there is a concern for sepsis 3.
• In cases of mastitis caused by methicillin-resistant Staphylococcus aureus (MRSA), treatment with antibiotics effective against this organism may be necessary 2, 4, 5.

Prevention of Mastitis

• Frequent, complete emptying of the breast and optimizing breastfeeding technique can reduce the risk of mastitis 2.
• A proper lactation technique, including a good infant latch, and encouraging physiologic breastfeeding rather than pumping, can also help prevent mastitis 3.
• Avoiding overstimulation of milk production and tissue trauma from aggressive breast massage can also reduce the risk of mastitis 3.