What are alternative antibiotic options for breast abscess (infection) coverage in a lactating (breastfeeding) woman, specifically for Methicillin-resistant Staphylococcus aureus (MRSA) infection, who has been breastfeeding for 3 months?

From the Guidelines

For a lactating woman with a breast abscess caused by methicillin-resistant Staphylococcus aureus (MRSA), the most appropriate antibiotic options include clindamycin 300-450 mg orally four times daily for 7-14 days or doxycycline 100 mg twice daily for 7-14 days, as these provide good coverage against MRSA and are compatible with breastfeeding, especially since the infant is older than 3 months 1.

Key Considerations

• Incision and drainage of the abscess is crucial for treatment success, in addition to antibiotic therapy.
• The mother can continue breastfeeding during treatment, though she may need to express milk from the affected breast if too painful.
• Warm compresses before feeding and proper breast emptying will help with healing.
• Pain management with acetaminophen or ibuprofen is also appropriate during treatment.

Antibiotic Options

• Clindamycin provides good coverage against MRSA and is compatible with breastfeeding.
• Doxycycline is typically safe for short-term use while breastfeeding an infant older than 3 months.
• Trimethoprim-sulfamethoxazole (TMP-SMX) is generally considered first-line for MRSA but should be used with caution in breastfeeding women with infants younger than 2 months due to potential bilirubin displacement 1.

Breastfeeding and MRSA Treatment

• Breastfeeding can continue on the affected side as long as the infant’s mouth does not contact purulent material from the abscess.
• Regular feeding or expression of milk is an adjunct to other treatment and can help prevent the progression of mastitis to breast abscess 1.

From the FDA Drug Label

The in vitro spectrum of activity of linezolid also includes certain Gram-negative bacteria and anaerobic bacteria Linezolid has been shown to be active against most isolates of the following microorganisms, both in vitro and in clinical infections... Staphylococcus aureus (including methicillin-resistant strains)

Alternative antibiotic options for breast abscess (infection) coverage in a lactating woman, specifically for MRSA infection:

• Linezolid is an option for the treatment of MRSA infections, as it has been shown to be active against most isolates of Staphylococcus aureus, including methicillin-resistant strains 2.
• The cure rates for MRSA skin and skin structure infection were 79% for linezolid-treated patients and 73% for vancomycin-treated patients 2.
• Linezolid may be considered as an alternative to vancomycin for the treatment of MRSA infections in lactating women, but its use should be carefully evaluated on a case-by-case basis, considering the potential risks and benefits 2.
• Vancomycin is also an option for the treatment of MRSA infections, and it can be used in combination with other antibiotics, such as aztreonam, if clinically indicated 2.
• Ampicillin/sulbactam or amoxicillin/clavulanate may also be considered as alternative options for the treatment of skin and skin structure infections, including those caused by MRSA, although their effectiveness against MRSA may be lower compared to linezolid or vancomycin 2.

From the Research

Alternative Antibiotic Options for MRSA Infection in Lactating Women

• For a lactating woman with a breast abscess due to Methicillin-resistant Staphylococcus aureus (MRSA) infection, alternative antibiotic options are crucial to ensure effective treatment while considering the safety of the breastfeeding infant 3, 4, 5, 6, 7.
• The choice of antibiotic should be based on the susceptibility pattern of the causative organism, and in the case of MRSA, antibiotics such as clindamycin and ciprofloxacin are recommended as initial empirical therapy 5.
• Other antibiotics that may be considered for the treatment of MRSA infections in lactating women include linezolid, quinupristin-dalfopristin, tigecycline, and trimethoprim-sulfamethoxazole, although the safety data for these agents in breastfeeding infants is limited 6.
• It is essential to note that the excretion of antibiotics in breast milk is a critical consideration, and most antibiotics, including those used to treat MRSA infections, are considered safe for use during breastfeeding, albeit with close monitoring of the infant 6.

Safety of Antibiotics in Breastfeeding Infants

• The safety of antibiotics in breastfeeding infants has been evaluated, and most antibiotics, including clindamycin, rifampin, tetracyclines, trimethoprim-sulfamethoxazole, and vancomycin, appear to be relatively safe in the minimal quantities ingested through breast milk 6.
• However, the paucity of data on the safety of newer antibiotics, such as linezolid, quinupristin-dalfopristin, tigecycline, and daptomycin, necessitates close monitoring of breastfed infants whose mothers are receiving these agents 6.

Treatment Approach for Breast Abscesses in Lactating Women

• The treatment approach for breast abscesses in lactating women should involve a conservative approach with antibiotic therapy targeted at MRSA, along with needle aspiration, if feasible 4.
• This approach has been shown to be effective in managing breast abscesses, with a low risk of recurrence and minimal disruption to breastfeeding 4.