What is the best treatment for mastitis in a breastfeeding female?

Best Treatment for Mastitis in Breastfeeding Women

The best treatment for mastitis in breastfeeding women includes continued breastfeeding or milk expression, supportive measures, and antibiotics effective against Staphylococcus aureus such as cephalexin or dicloxacillin when conservative management fails after 1-2 days. 1, 2

Initial Management Approach

• Continue breastfeeding or milk expression from the affected breast, which is essential for treatment and helps resolve the condition 1, 3
• Start with a 1-2 day trial of conservative measures before antibiotics, including:
  • Nonsteroidal anti-inflammatory drugs for pain management 2
  • Ice application to reduce inflammation 2
  • Ensure proper infant latch and breastfeeding technique 2
• Avoid practices that may worsen the condition:
  • Excessive pumping or overfeeding 2
  • Aggressive breast massage 2
  • Heat application 2

Antibiotic Therapy

If symptoms don't improve after 1-2 days of conservative management:

• First-line antibiotics (effective against Staphylococcus aureus):

  • Cephalexin 1, 4
  • Dicloxacillin 4, 5
  • Amoxicillin/clavulanic acid (alternative option) 1

• For penicillin-allergic patients:

  • Erythromycin or azithromycin, though there is a very low risk of infantile hypertrophic pyloric stenosis in infants exposed during the first 13 days of breastfeeding 1
  • Clindamycin (for severe penicillin allergy) 1

• Consider MRSA coverage if:

  • Local MRSA prevalence is high 1
  • Previous MRSA infection 1
  • No response to first-line therapy 1

Duration and Follow-up

• Standard antibiotic course is typically 10-14 days 4
• If symptoms worsen or do not improve within 48-72 hours of starting antibiotics, reevaluation is necessary to rule out an abscess 1
• Consider obtaining milk cultures to guide antibiotic therapy in cases of:
  • Treatment failure 2
  • Recurrent mastitis 2
  • Immunocompromised patients 2

Management of Complications

• Breast abscess (occurs in approximately 10% of mastitis cases):
  • Requires drainage via surgical incision or needle aspiration 3, 4
  • Ultrasonography should be performed to identify abscesses in cases of worsening or recurrent symptoms 2
  • Breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage 3

Important Considerations

• Continued breastfeeding during antibiotic treatment does not pose a risk to the infant 1
• All recommended antibiotics are considered compatible with breastfeeding, with minimal transfer to breast milk 1
• Discontinuing breastfeeding during mastitis treatment can worsen the condition 3
• The risk of mastitis can be reduced by frequent, complete emptying of the breast and optimizing breastfeeding technique 4
• Sore nipples can precipitate mastitis; address underlying causes such as poor latch or infant mouth anomalies 4

When to Consider Hospitalization

• Worsening condition despite oral antibiotics 2
• Signs of sepsis 2
• Need for intravenous antibiotics 2
• Immunocompromised patient 2