What is the recommended treatment for mastitis in an inpatient setting?

Treatment of Mastitis in the Inpatient Setting

The recommended treatment for mastitis in an inpatient setting includes continued breastfeeding, appropriate antibiotic therapy targeting Staphylococcus aureus (such as dicloxacillin, cephalexin, or antibiotics effective against MRSA if suspected), pain management, and drainage of any abscess if present. 1, 2

Initial Assessment and Management

• Patients requiring inpatient management typically have severe symptoms, systemic illness, or complications such as abscess formation 1
• Continue breastfeeding or milk expression from the affected breast as this is an essential part of treatment 3, 4
• Regular feeding or expression of milk helps prevent milk stasis and is considered an adjunct to other treatments 4
• Avoid aggressive breast massage, excessive pumping, and heat application as these can worsen inflammation 1

Antibiotic Therapy

• Intravenous antibiotics are indicated for inpatients with mastitis 1

• First-line antibiotics should target Staphylococcus aureus, the most common pathogen 2, 5

• Recommended IV antibiotics include:

  • Dicloxacillin or nafcillin 2
  • First-generation cephalosporins (cefazolin) 2
  • Consider MRSA coverage if risk factors present or local prevalence is high 6

• For suspected or confirmed MRSA:

  • Vancomycin (with appropriate therapeutic monitoring) 4
  • Linezolid may be superior to vancomycin for MRSA pneumonia and could be considered for severe cases 4
  • Daptomycin may be preferred for MRSA with vancomycin MIC >1 mg/L 4

Management of Complications

• Approximately 10% of mastitis cases progress to breast abscess formation 4, 2
• Ultrasound should be performed to identify abscesses in patients with worsening or recurrent symptoms 1
• Breast abscesses require drainage, either by surgical incision or needle aspiration 4, 5
• Breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage 4
• For neonatal mastitis (which is less common), aggressive IV antibiotic therapy with agents effective against S. aureus is recommended, with approximately 50% of cases resolving without surgical intervention 5

Supportive Care

• Provide adequate pain management with NSAIDs 1
• Apply ice to the affected area to reduce inflammation 1
• Ensure proper lactation technique, including optimal infant latch 1
• Consider milk cultures to guide antibiotic therapy in non-responsive cases 1

Transition to Outpatient Care

• Once clinically improved with resolution of fever and systemic symptoms, transition to oral antibiotics 2
• Complete a 10-14 day total course of antibiotics 2
• Provide education on proper breastfeeding technique to prevent recurrence 1, 2
• Arrange follow-up to ensure complete resolution 2

Special Considerations

• For immunocompromised patients, more aggressive treatment and monitoring may be required 1
• Recurrent mastitis may indicate inadequate initial treatment, poor breastfeeding technique, or possibly candida infection as a complication of antibiotic therapy 7
• Discontinuing breastfeeding during mastitis treatment can worsen the condition and is not recommended 3