Treatment of Mastitis
The recommended first-line treatment for mastitis is a combination of effective milk removal, pain management with NSAIDs, and antibiotics effective against Staphylococcus aureus such as dicloxacillin or cephalexin if symptoms don't improve after 1-2 days of conservative measures. 1
Diagnosis and Clinical Presentation
Mastitis is diagnosed clinically based on:
- Focal breast tenderness
- Overlying skin erythema or hyperpigmentation
- Systemic symptoms like fever and malaise
- Typically occurs in the first 3 months postpartum
Laboratory tests and imaging are generally not required for initial diagnosis, though milk cultures may be considered to guide antibiotic therapy in cases that don't respond to initial treatment 1.
Treatment Algorithm
Step 1: Conservative Management (1-2 days)
- Continue breastfeeding from the affected breast to ensure effective milk removal
- Apply ice for pain relief
- Take nonsteroidal anti-inflammatory drugs (NSAIDs)
- Minimize pumping (contrary to previous recommendations of aggressive emptying)
- Avoid excessive heat application and aggressive breast massage as these may worsen the condition 1
Step 2: If No Improvement After 1-2 Days
- Initiate antibiotic therapy targeting common skin flora:
- Dicloxacillin 500 mg every 6 hours
- Cephalexin 500 mg every 6 hours
- Continue for 10-14 days
Step 3: For Non-responsive Cases
- Consider milk culture to guide antibiotic therapy
- Evaluate for possible abscess with ultrasonography
- Consider methicillin-resistant S. aureus (MRSA) coverage if indicated by local resistance patterns 2
Special Considerations
Medication Safety During Breastfeeding
- Dicloxacillin transfers minimally into breast milk (relative infant dose of only 0.03%) and is considered safe during breastfeeding 3
- Continued breastfeeding during antibiotic treatment is recommended and generally does not pose a risk to the infant 2
Complications and Follow-up
- Breast abscess is the most common complication of mastitis
- If an abscess develops, surgical drainage or needle aspiration is needed
- Ultrasonography should be performed in immunocompromised patients or those with worsening or recurrent symptoms 1
Prevention
- Proper lactation technique, including good infant latch
- Encourage physiologic breastfeeding rather than pumping when possible
- Avoid practices that may cause overstimulation of milk production or tissue trauma 1
Evidence Quality
The evidence supporting antibiotic use in mastitis is somewhat limited. A Cochrane review found insufficient evidence to definitively confirm or refute antibiotic effectiveness for lactational mastitis 4. However, clinical practice guidelines and expert opinion support the use of antibiotics when conservative measures fail, particularly given the potential complications of untreated bacterial mastitis.
Most cases of mastitis are initially inflammatory rather than infectious, which is why a 1-2 day trial of conservative measures is appropriate before starting antibiotics 1. This approach helps reduce unnecessary antibiotic use while ensuring appropriate treatment for cases that truly require antimicrobial therapy.