What is the recommended treatment for mastitis with fever?

Treatment for Mastitis with Fever

The recommended first-line treatment for mastitis with fever is a 7-10 day course of an antibiotic effective against Staphylococcus aureus (such as dicloxacillin or cephalexin), combined with continued breastfeeding and supportive measures including NSAIDs and proper breast emptying. 1, 2

Initial Management Approach

Conservative Measures (1-2 days)

• Begin with conservative measures for 1-2 days as most cases of mastitis are inflammatory rather than infectious 1
• Continue breastfeeding from the affected breast to ensure complete emptying 1, 2
• Use NSAIDs for pain relief and anti-inflammatory effects 1
• Apply ice to the affected area to reduce inflammation 1
• Minimize pumping and avoid excessive breast emptying which can worsen inflammation 1
• Avoid heat application and aggressive breast massage which can increase inflammation 1

When to Start Antibiotics

• If no improvement after 1-2 days of conservative measures 1
• Immediately if symptoms are severe (high fever, significant erythema, systemic illness) 2
• If patient is immunocompromised 1
• If there are signs of abscess formation 2

Antibiotic Selection

First-line Antibiotics

• Dicloxacillin 500 mg orally four times daily for 7-10 days 2, 3
• Cephalexin 500 mg orally four times daily for 7-10 days (alternative first-line) 2

For Penicillin Allergic Patients

• Clindamycin 300-450 mg orally four times daily for 7-10 days 2

For Suspected MRSA

• Consider trimethoprim-sulfamethoxazole or clindamycin if MRSA is suspected or prevalent in your community 2

Special Considerations

Milk Culture

• Consider obtaining milk cultures to guide antibiotic therapy, especially in:
  • Cases not responding to initial therapy 1
  • Recurrent mastitis 1
  • Hospital-acquired cases 2
  • Severe cases 2

Imaging

• Ultrasound is indicated if:
  • Symptoms worsen despite 48-72 hours of appropriate antibiotics 1
  • Recurrent episodes of mastitis 1
  • Suspicion of abscess (fluctuant mass, severe pain) 2
  • Immunocompromised patients 1

Hospitalization Criteria

• Severe systemic symptoms or signs of sepsis 1
• Failed outpatient treatment 2
• Immunocompromised patient 1
• Need for intravenous antibiotics 1

Complications and Management

Breast Abscess

• Most common complication of inadequately treated mastitis 2
• Presents as a fluctuant, tender mass that may not improve with antibiotics 2
• Management requires surgical drainage or ultrasound-guided needle aspiration 2
• Continue antibiotics and breastfeeding during treatment 2

Prevention Strategies

Optimal Breastfeeding Technique

• Ensure proper infant latch with assistance of lactation consultant if needed 1, 2
• Encourage complete emptying of breasts during feeds 1
• Avoid prolonged intervals between feeds 2
• Address sore nipples promptly as they can lead to mastitis 2
• Avoid excessive pumping and overproduction of milk 1

Common Pitfalls to Avoid

• Discontinuing breastfeeding during mastitis treatment (this can worsen the condition) 2, 3
• Delaying antibiotics in severe cases 2
• Missing an abscess that requires drainage 1, 2
• Failing to address underlying breastfeeding issues that may lead to recurrent mastitis 1
• Using antibiotics unnecessarily for mild cases that would resolve with conservative measures 1, 4
• Applying heat and aggressive massage, which can worsen inflammation 1