Treatment of Mastitis
For lactational mastitis, initial treatment should include conservative measures for 1-2 days (NSAIDs, ice application, continued breastfeeding), followed by antibiotics effective against Staphylococcus aureus (dicloxacillin or cephalexin) if symptoms don't improve. 1
Types of Mastitis and Diagnosis
Mastitis represents a spectrum of inflammatory conditions of the breast, with lactational mastitis being the most common form, affecting approximately 10% of breastfeeding women in the United States 1. It typically occurs within the first three months postpartum.
The diagnosis is primarily clinical, based on:
- Fever
- Malaise
- Focal breast tenderness
- Overlying skin erythema or hyperpigmentation
Laboratory tests or imaging are not routinely needed for diagnosis 1.
Treatment Algorithm
Step 1: Conservative Management (1-2 days)
- NSAIDs for pain and inflammation
- Ice application to affected area
- Continue breastfeeding directly from the affected breast
- Minimize pumping
- Ensure proper positioning and latch of infant
Step 2: If No Improvement After 1-2 Days
- Initiate antibiotics effective against common skin flora (Staphylococcus and Streptococcus species)
- First-line options:
- Dicloxacillin
- Cephalexin (e.g., cephalexin)
Step 3: For Suspected MRSA
- Consider MRSA-effective antibiotics if:
- No improvement with first-line therapy
- Known MRSA colonization
- Healthcare worker
- Previous MRSA infection
- High community prevalence of MRSA 2
Step 4: For Severe Cases or Complications
- Consider hospitalization and IV antibiotics if:
- Signs of sepsis
- Immunocompromised patient
- Worsening despite oral antibiotics 1
- Obtain ultrasonography if:
- Worsening or recurrent symptoms
- Suspicion of abscess
- Immunocompromised patient 1
Special Considerations
Continued Breastfeeding
- Continued breastfeeding should be encouraged during mastitis treatment
- It helps with breast drainage and does not pose a risk to the infant 3
Abscess Management
- Breast abscess is the most common complication of mastitis
- Requires surgical drainage or needle aspiration
- Breastfeeding can usually continue with a treated abscess 3
Candidal Mastitis
While some cases of nipple or breast pain in nursing mothers have been linked to Candida albicans, the true cause remains unclear. If suspected, treatment of both mother and infant with an antifungal agent may provide relief 4.
Prevention
The risk of mastitis can be reduced by:
- Ensuring proper infant latch
- Encouraging physiologic breastfeeding rather than pumping when possible
- Avoiding practices that overstimulate milk production:
- Excessive pumping
- Aggressive breast massage
- Overfeeding
- Heat application 1
Evidence Quality
The evidence for antibiotic treatment in mastitis is surprisingly limited. A Cochrane review found insufficient evidence to confirm or refute the effectiveness of antibiotic therapy for lactational mastitis, highlighting the need for high-quality randomized controlled trials 5. However, clinical practice guidelines and expert opinion support the use of antibiotics when conservative measures fail, particularly given the risk of abscess formation if mastitis is undertreated 3, 1.
The emergence of MRSA as a causative organism in mastitis is an important consideration, particularly in patients who fail to respond to conventional antibiotics 2.