What is the recommended treatment for mastitis?

Treatment for Mastitis

For lactational mastitis, treatment should include continued breastfeeding along with antibiotics effective against Staphylococcus aureus (such as dicloxacillin or cephalexin) if symptoms persist beyond 24-48 hours of conservative measures. 1

Diagnosis and Initial Assessment

• Mastitis is diagnosed clinically based on:

  • Focal breast tenderness
  • Overlying skin erythema or hyperpigmentation
  • Systemic symptoms (fever, malaise)
  • Typically occurs within first 3 months postpartum
  • Affects approximately 10% of breastfeeding women in the US 2, 1

• No laboratory tests or imaging are routinely required for initial diagnosis 1

Treatment Algorithm

Step 1: Conservative Management (1-2 days)

• Most cases of mastitis are inflammatory rather than infectious initially 1
• First-line treatment includes:
  • Continue breastfeeding from the affected breast
  • Nonsteroidal anti-inflammatory drugs for pain and inflammation
  • Ice application to reduce pain and swelling
  • Ensure proper infant latch and breastfeeding technique
  • Minimize excessive pumping (contrary to previous recommendations) 1

Step 2: Antibiotic Therapy

• Indicated if:

  • No improvement after 24-48 hours of conservative measures
  • Severe symptoms from onset
  • Signs of systemic illness

• Preferred antibiotics:

  • Dicloxacillin or cloxacillin (first-line) 3
  • Cephalexin (alternative) 2
  • Duration: typically 10-14 days

• These antibiotics are effective against Staphylococcus aureus, the most common causative organism 2

Step 3: Management of Complications

• For worsening symptoms or suspected abscess:
  • Ultrasound evaluation 1
  • Surgical drainage or needle aspiration for confirmed abscess 2
  • Consider milk culture in cases of:
    • Treatment failure
    • Recurrent mastitis
    • Immunocompromised patients 1

Special Considerations

• Continued breastfeeding is essential and does not pose a risk to the infant 2, 4

  • Helps with milk removal, which is crucial for recovery
  • Prevents milk stasis that can worsen inflammation

• Avoid practices that may worsen mastitis:

  • Excessive pumping
  • Aggressive breast massage
  • Heat application
  • Overfeeding 1

• Prevention strategies:

  • Proper lactation technique with good infant latch
  • Physiologic breastfeeding rather than excessive pumping
  • Prompt treatment of sore nipples, which can precipitate mastitis 2

Emerging Considerations

• Methicillin-resistant S. aureus (MRSA) is becoming more common and may require different antibiotic choices 2

• Evidence for antibiotic effectiveness is limited:

  • Cochrane review found insufficient evidence to confirm or refute antibiotic effectiveness 5
  • Clinical practice still supports antibiotic use for cases not responding to conservative measures

Mammary Candidiasis

• If symptoms persist despite appropriate treatment, consider mammary candidiasis 4
• Presents with nipple or breast pain in nursing mothers
• Treatment involves antifungal therapy for both mother and infant

The most important aspects of mastitis management are continued breastfeeding, proper breastfeeding technique, and appropriate antibiotic therapy when indicated. Early intervention can prevent complications such as breast abscess formation.