What is the management of mastitis?

Management of Mastitis

The management of mastitis primarily involves conservative measures including frequent breast emptying, proper breastfeeding technique, and pain management, with antibiotics reserved for cases that don't improve within 24-48 hours or show signs of infection. 1

Diagnosis

• Mastitis is diagnosed clinically based on symptoms including focal breast tenderness, fever, malaise, and overlying skin erythema or hyperpigmentation 1
• Laboratory tests or imaging are generally not required for initial diagnosis 1
• Milk cultures should be considered to guide antibiotic therapy in cases that don't respond to initial treatment or in immunocompromised patients 1
• Ultrasonography should be performed to identify potential breast abscesses in patients with worsening or recurrent symptoms 1

Initial Management Approach

Conservative Measures (First 24-48 hours)

• Effective milk removal is the most essential part of treatment and may make antibiotics unnecessary 2
• Continue breastfeeding from the affected breast to prevent milk stasis 3, 2
• Apply ice to reduce inflammation and pain 1
• Use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation 1
• Minimize excessive pumping as it may worsen the condition 1

Breastfeeding Technique Optimization

• Ensure proper infant latch and positioning at the breast 3, 1
• Consider consultation with a lactation specialist to improve technique 3
• Address any sore nipples, which can precipitate mastitis 3

Antibiotic Therapy

When to Initiate Antibiotics

• Start antibiotics if no improvement after 1-2 days of conservative measures 1
• Immediate antibiotic therapy is indicated for severe symptoms, immunocompromised patients, or signs of sepsis 1

Antibiotic Selection

• First-line antibiotics should be effective against Staphylococcus aureus, the most common causative organism 3, 2
• Recommended antibiotics include:
  • Dicloxacillin or cloxacillin as first-line drugs 2
  • Cephalexin as an alternative option 3
• For suspected methicillin-resistant S. aureus (MRSA), appropriate coverage should be provided 3
• Duration of therapy is typically 10-14 days 3

Route of Administration

• Most patients can be treated as outpatients with oral antibiotics 1
• Intravenous antibiotics and hospital admission may be required for:
  • Worsening symptoms despite oral antibiotics 1
  • Signs of sepsis 1
  • Immunocompromised patients 1

Management of Complications

Breast Abscess

• Most common complication of mastitis 3
• Prevention through early treatment of mastitis and continued breastfeeding 3
• If abscess develops, surgical drainage or needle aspiration is required 3
• Breastfeeding can usually continue with a treated abscess 3

Prevention Strategies

• Optimize breastfeeding technique, including proper infant latch 1
• Encourage physiologic breastfeeding rather than pumping when possible 1
• Avoid practices that may increase risk:
  • Overstimulation of milk production 1
  • Excessive pumping to empty the breast 1
  • Aggressive breast massage 1
  • Excessive heat application 1

Special Considerations

• Continued breastfeeding during mastitis treatment is generally safe and recommended 3, 2
• Transfer of antibiotics like dicloxacillin/cloxacillin to breast milk is minimal and not harmful to the infant 2
• Evidence for probiotics in treatment or prevention is currently insufficient 1