What is the recommended treatment for mastitis?

Treatment of Mastitis

The recommended first-line treatment for mastitis includes effective milk removal, pain management with NSAIDs, and antibiotics effective against Staphylococcus aureus such as dicloxacillin or cephalexin when symptoms persist beyond 24-48 hours of conservative measures. 1, 2

Diagnosis and Clinical Presentation

Mastitis is an inflammatory condition of the breast that occurs in approximately 10% of breastfeeding women in the United States, typically within the first three months postpartum 1, 2. Diagnosis is primarily clinical, based on:

• Focal breast tenderness
• Overlying skin erythema or hyperpigmentation
• Systemic symptoms (fever, malaise)
• Swollen, red, hot, and painful breast

Treatment Algorithm

Step 1: Conservative Management (1-2 days)

• Continue breastfeeding from the affected breast to ensure effective milk removal
• Apply ice to reduce inflammation
• Take NSAIDs for pain and inflammation
• Minimize pumping (contrary to previous recommendations)
• Avoid excessive breast massage, which may worsen the condition 2

Step 2: If No Improvement After 24-48 Hours

• Start antibiotics effective against Staphylococcus aureus:
  • Dicloxacillin 500 mg orally every 6 hours 3
  • Cephalexin 500 mg orally every 6 hours 1
  • Continue for 10-14 days

Step 3: For Worsening Symptoms or No Response

• Consider milk culture to guide antibiotic therapy 2
• Evaluate for breast abscess with ultrasound, especially in:
  • Immunocompromised patients
  • Those with worsening or recurrent symptoms
  • Cases with a palpable mass
• If abscess is present, surgical drainage or needle aspiration is required 1

Special Considerations

• Continue breastfeeding: This is safe and recommended during mastitis treatment and generally does not pose a risk to the infant 1, 4
• Antibiotic safety: Dicloxacillin transfers minimally into breast milk (relative infant dose of only 0.03%), making it safe during breastfeeding 3
• MRSA concerns: As methicillin-resistant S. aureus becomes more common, consider antibiotics effective against MRSA if no improvement with first-line therapy 1

Prevention Strategies

• Optimize breastfeeding technique with proper infant latch
• Encourage physiologic breastfeeding rather than pumping when possible
• Avoid practices that overstimulate milk production:
  • Excessive pumping
  • Overfeeding
  • Aggressive breast massage 2

Evidence Quality and Limitations

The Cochrane review on antibiotics for mastitis found insufficient evidence to confirm or refute the effectiveness of antibiotic therapy, highlighting the need for high-quality randomized controlled trials 5. However, clinical practice guidelines and expert opinion support the use of antibiotics when symptoms persist beyond conservative management.

While some older recommendations suggested practices like heat application, frequent breast emptying, and aggressive massage, newer evidence indicates these may worsen inflammation and are no longer recommended 2.

Monitoring and Follow-up

• Improvement should be seen within 48 hours of starting antibiotics
• If symptoms worsen or do not improve, consider:
  • Ultrasound to rule out abscess
  • Milk culture to guide antibiotic selection
  • Possible hospitalization for intravenous antibiotics in severe cases 2