What is the recommended treatment for mastitis?

Treatment for Mastitis

The recommended first-line treatment for lactational mastitis is a 1-2 day trial of conservative measures including nonsteroidal anti-inflammatory drugs, ice application, continued breastfeeding from the affected breast, and minimizing pumping, followed by antibiotics effective against Staphylococcus aureus (such as dicloxacillin or cephalexin) if symptoms do not improve. 1

Understanding Mastitis

Mastitis is an inflammatory condition of the breast that affects approximately 10% of breastfeeding women in the United States, typically occurring within the first 3 months postpartum 1, 2. It presents clinically with:

• Focal breast tenderness
• Overlying skin erythema or hyperpigmentation
• Fever
• Malaise

Treatment Algorithm

Step 1: Conservative Management (1-2 days)

Since most cases of mastitis are caused by inflammation rather than true infection, initial treatment should focus on:

• NSAIDs for pain and inflammation
• Ice application to the affected area
• Continued breastfeeding directly from the affected breast
• Minimizing pumping 1

Step 2: Antibiotic Therapy

If no improvement after 1-2 days of conservative measures, initiate antibiotic therapy:

• First-line antibiotics: Those effective against Staphylococcus aureus

  • Dicloxacillin 500 mg orally every 6 hours 3, 4
  • Cephalexin 500 mg orally every 6 hours 2

• Duration: Typically 10-14 days

• Safety in breastfeeding: Dicloxacillin has minimal transfer into breast milk (relative infant dose of only 0.03%) and is considered safe during breastfeeding 3

Step 3: Advanced Management

For worsening symptoms or complications:

• Milk culture: Consider obtaining milk cultures to guide antibiotic therapy in cases of:

  • Treatment failure
  • Recurrent mastitis
  • Immunocompromised patients 1

• Imaging: Perform ultrasonography to identify breast abscess in:

  • Immunocompromised patients
  • Patients with worsening symptoms
  • Cases of recurrent mastitis 1

• Abscess management: If abscess develops, surgical drainage or needle aspiration is needed 2

• Hospitalization: Consider for severe cases with signs of sepsis requiring intravenous antibiotics 1

Important Considerations

Breastfeeding Continuation

• Continued breastfeeding should be encouraged during mastitis treatment
• Breastfeeding from the affected breast does not pose a risk to the infant and helps with breast emptying 2

Prevention Strategies

• Optimize breastfeeding technique with proper infant latch
• Encourage physiologic breastfeeding rather than pumping when possible
• Avoid practices that may worsen the condition:
  • Excessive pumping to empty the breast
  • Heat application
  • Aggressive breast massage
  • Overfeeding 1

Common Pitfalls to Avoid

1. Stopping breastfeeding: This can worsen milk stasis and delay recovery
2. Delaying antibiotics in cases with severe symptoms or signs of infection
3. Missing an abscess: Consider imaging in cases that don't respond to treatment
4. Inadequate antibiotic coverage: With increasing prevalence of methicillin-resistant S. aureus (MRSA), consider broader coverage if no improvement with first-line therapy 2
5. Overtreatment: Not all cases require antibiotics immediately; many respond to conservative measures 1

While a Cochrane review found insufficient evidence to confirm the effectiveness of antibiotic therapy for lactational mastitis 5, clinical practice guidelines and recent evidence support the approach outlined above, with antibiotics reserved for cases that don't respond to conservative measures or present with significant signs of infection.