What is the treatment for mastitis, especially when caused by a bacterial infection?

Treatment of Mastitis

Mastitis treatment should begin with effective milk removal through continued breastfeeding, along with anti-inflammatory medication, followed by antibiotics if symptoms do not improve within 24-48 hours. 1

Initial Management

• Mastitis is an inflammation of the breast that commonly occurs in breastfeeding women, with an incidence of approximately 10% in the United States 2, 1
• First-line treatment should include:
  • Continued breastfeeding from the affected breast to ensure effective milk removal 2, 3
  • Non-steroidal anti-inflammatory drugs for pain and inflammation 1
  • Ice application to the affected area 1
  • Minimizing pumping (contrary to previous recommendations of aggressive emptying) 1

Antibiotic Therapy

If symptoms do not improve after 24-48 hours of conservative management, antibiotic therapy should be initiated:

• First-line antibiotics: Dicloxacillin or cloxacillin (flucloxacillin) are recommended as they target Staphylococcus aureus, the most common bacterial cause 4, 2, 3

  • Dosage: Dicloxacillin 500 mg orally every 6 hours for 7-10 days 5, 2

• Alternative antibiotics (for penicillin-allergic patients):

  • Cephalexin 500 mg orally every 6 hours (if no severe penicillin allergy) 4, 2
  • Clindamycin 300-450 mg orally every 6 hours (for severe penicillin allergy) 6

Clinical Pearls

• Milk cultures should be considered to guide antibiotic therapy, especially in cases of recurrent or severe mastitis 1
• Continued breastfeeding during antibiotic treatment is safe and recommended, as it helps resolve the condition and does not pose a risk to the infant 4, 2
• The transfer of dicloxacillin/cloxacillin to breast milk is minimal, making it safe during breastfeeding 3
• Avoid practices that may worsen mastitis:
  • Excessive pumping
  • Aggressive breast massage
  • Heat application (use ice instead)
  • Overstimulation of milk production 1

Monitoring and Complications

• If symptoms worsen despite oral antibiotics, consider:

  • Ultrasonography to identify possible breast abscess 1
  • Intravenous antibiotics and hospital admission if signs of sepsis develop 1

• Breast abscess is the most common complication of mastitis:

  • Requires surgical drainage or needle aspiration 2
  • Breastfeeding can usually continue even with a treated abscess 2

Prevention

• Optimize breastfeeding technique with proper infant latch 2, 1
• Encourage physiologic breastfeeding rather than pumping when possible 1
• Avoid sore nipples which can precipitate mastitis 2
• Frequent, complete emptying of the breast helps reduce risk 2

While there is limited high-quality evidence from randomized controlled trials on antibiotic effectiveness for mastitis 7, clinical experience and guidelines support the approach of initial conservative management followed by targeted antibiotic therapy when necessary, with continued breastfeeding throughout treatment 2, 3, 1.