What is the recommended treatment for mastitis in pregnant women?

From the Guidelines

The recommended treatment for mastitis in pregnant women is to continue breastfeeding or expressing milk from the affected breast, along with antibiotics and supportive measures, to prevent milk stasis and abscess formation, as stated by the American Academy of Pediatrics 1. Mastitis in pregnant women can be effectively managed with a combination of antibiotics, pain management, and supportive care.

• Antibiotics such as dicloxacillin or cephalexin are commonly used to treat mastitis in non-allergic patients, while clindamycin can be used for those with penicillin allergies, as these are effective against the most common causative organisms 1.
• Pain management with acetaminophen or ibuprofen at standard dosing can help alleviate symptoms, and warm compresses before feeding and cold compresses after can reduce pain and inflammation.
• It is essential for women to continue breastfeeding or expressing milk from the affected breast to prevent milk stasis and abscess formation, as regular feeding or expression of milk is an adjunct to other treatment, and breastfeeding can continue on the affected side as long as the infant’s mouth does not contact purulent material 1.
• Supportive measures such as adequate rest, increased fluid intake, and wearing a supportive, non-underwire bra are also crucial in managing mastitis.
• If symptoms don't improve within 48 hours of antibiotic therapy or if an abscess is suspected, prompt medical reevaluation is necessary to prevent complications such as abscess formation or sepsis, which can affect both maternal and fetal health during pregnancy.

From the FDA Drug Label

Pregnancy Category B Reproduction studies performed in the mouse, rat, and rabbit have revealed no evidence of impaired fertility or harm to the fetus due to the penicillinase-resistant penicillins Human experience with the penicillins during pregnancy has not shown any positive evidence of adverse effects on the fetus. There are, however, no adequate or well-controlled studies in pregnant women showing conclusively that harmful effects of these drugs on the fetus can be excluded Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

The recommended treatment for mastitis in pregnant women is not directly stated in the provided drug labels. However, dicloxacillin is a penicillinase-resistant penicillin that can be used during pregnancy if clearly needed, and it may be considered for the treatment of mastitis caused by susceptible bacteria.

• The decision to use dicloxacillin or any other antibiotic during pregnancy should be made after careful consideration of the potential benefits and risks, and under the guidance of a healthcare provider.
• It is essential to note that the FDA drug label for dicloxacillin does not provide specific guidance on the treatment of mastitis in pregnant women, and the use of this medication for this indication should be based on clinical judgment and available evidence 2.

From the Research

Mastitis in Pregnant Women

• Mastitis represents a spectrum of inflammatory conditions, and lactational mastitis is the most common type, usually occurring in the first 3 months postpartum 3.
• The diagnosis of mastitis is made clinically based on symptoms such as fever, malaise, focal breast tenderness, and overlying skin erythema or hyperpigmentation without the need for laboratory tests or imaging 3.
• Obtaining milk cultures should be considered to guide antibiotic therapy, and ultrasonography should be performed to identify abscesses in immuno-compromised patients or those with worsening or recurrent symptoms 3.

Treatment of Mastitis

• A 1- to 2-day trial of conservative measures (i.e., nonsteroidal anti-inflammatory drugs, ice application, feeding the infant directly from the breast, and minimizing pumping) is often sufficient for treatment 3.
• If there is no improvement in symptoms, narrow-spectrum antibiotics may be prescribed to cover common skin flora (e.g., Staphylococcus, Streptococcus) 3, 4.
• Most patients can be treated as outpatients with oral antibiotics; however, if the condition worsens or there is a concern for sepsis, intravenous antibiotics and hospital admission may be required 3.

Prevention of Mastitis

• The best prevention is a proper lactation technique, including a good infant latch, and encouraging physiologic breastfeeding rather than pumping, if possible 3.
• Factors that increase the risk of mastitis include overstimulation of milk production and tissue trauma from aggressive breast massage; therefore, frequent overfeeding, excessive pumping to empty the breast, heat application, and breast massage are no longer recommended because they may worsen the condition 3.
• Continued breastfeeding should be encouraged in the presence of mastitis and generally does not pose a risk to the infant 4, 5.

Antibiotic Therapy

• There is insufficient evidence to confirm or refute the effectiveness of antibiotic therapy for the treatment of lactational mastitis 6, 7.
• The choice of a proper treatment and the provision of therapeutic instructions to the patient are crucial for a cure, for a successful duration of breastfeeding, and for preventing complications for mother and baby 5.