What is the first-line treatment for mastitis?

First-Line Treatment for Mastitis

The first-line treatment for mastitis includes continued breastfeeding from the affected breast along with appropriate antibiotics effective against Staphylococcus aureus, such as dicloxacillin or cloxacillin. 1

Understanding Mastitis

Mastitis is an inflammation of the breast tissue that occurs in approximately 10% of breastfeeding women in the United States 2. It typically presents with:

• Focal breast tenderness
• Redness, swelling, and warmth in the affected area
• Fever and systemic symptoms (malaise)
• Pain during breastfeeding

Treatment Algorithm

1. Effective Milk Removal (Essential First Step)

• Continue breastfeeding from the affected breast 1
• Regular and complete emptying of the breast is crucial
• Milk expression (manual or pump) if direct breastfeeding is too painful
• Proper positioning and latch technique, often with assistance from a lactation consultant

2. Antimicrobial Therapy

When antibiotics are warranted (signs of infection):

• First-line antibiotics: Dicloxacillin or cloxacillin 3

  • These are effective against Staphylococcus aureus, the most common causative organism
  • Minimal transfer to breast milk, safe for infant

• Alternative options:

  • Cephalexin (e.g., cephalexin) 2
  • Consider antibiotics effective against methicillin-resistant S. aureus (MRSA) if prevalent in your area 2

3. Pain Management

• Analgesics (e.g., ibuprofen) to reduce pain and inflammation
• Warm compresses before feeding to improve milk flow
• Cold compresses after feeding to reduce pain and swelling

Evidence Quality and Considerations

The evidence for antibiotic treatment in mastitis is somewhat limited. A Cochrane review found insufficient high-quality evidence to definitively confirm or refute antibiotic effectiveness 4. However, clinical practice guidelines and expert consensus support antibiotic use when signs of infection are present.

Important Clinical Pearls

• Milk culture may be necessary to determine the infecting organism and its antibiotic sensitivity, especially in severe or recurrent cases 3
• Continue breastfeeding during treatment - this is safe for the infant and helps resolve the mastitis 1, 2
• Monitor closely for abscess formation (occurs in approximately 10% of mastitis cases) 1
• If an abscess develops, surgical drainage or needle aspiration is required, but breastfeeding can usually continue 2

Prevention Strategies

• Frequent, complete emptying of the breast
• Optimizing breastfeeding technique
• Addressing sore nipples promptly (can precipitate mastitis)
• Avoiding sudden changes in feeding frequency

When to Consider Specialist Referral

• No improvement after 48 hours of appropriate antibiotics
• Signs of abscess formation (fluctuance, severe pain)
• Recurrent episodes of mastitis
• Unusual presentation or course

By implementing prompt and appropriate treatment focusing on continued breastfeeding and effective antimicrobial therapy when indicated, most cases of mastitis can be successfully managed while allowing continued breastfeeding.