What antibiotics are safe for use during breast-feeding?

Antibiotics Safe for Breastfeeding

Most β-lactam antibiotics, including penicillins and cephalosporins, are considered safe during breastfeeding and should be used as first-line options when appropriate for the infection. 1, 2

Safe First-Line Antibiotics for Breastfeeding Mothers

Penicillins

• Amoxicillin and amoxicillin/clavulanic acid are explicitly recommended as safe options for breastfeeding mothers requiring antibiotic therapy 2
• Penicillins are considered compatible with breastfeeding with minimal adverse effects on nursing infants 3
• These antibiotics have limited excretion into breast milk and pose minimal risk to the infant 4

Cephalosporins

• Cephalosporins (like cephalexin) are generally considered safe during breastfeeding 5
• First-generation cephalosporins are particularly recommended for skin and soft tissue infections in breastfeeding women 5
• Cephalosporins have minimal transfer to breast milk and limited impact on the nursing infant 1

Macrolides

• Erythromycin and azithromycin are suggested as safe options for breastfeeding patients 1, 6
• These can be used as alternatives for penicillin-allergic patients 6
• Caution: There is a very low risk of infantile hypertrophic pyloric stenosis in infants exposed to macrolides during the first 13 days of breastfeeding 6

Other Safe Antibiotics

• Metronidazole is suggested as safe for breastfeeding patients 1
• Rifampin can be used in breastfeeding patients with an approach similar to other patient populations 1

Antibiotics to Use with Caution or Avoid

• Clindamycin should be used with caution as it may increase the risk of GI side effects in the infant 1
• Tetracyclines (including doxycycline) should be limited; if no suitable alternative is available, use should be limited to 3 weeks without repeating courses 1
• Fluoroquinolones should not be administered as first-line treatment, though if clinically indicated, breastfeeding interruption is not necessary as the risk of adverse effects is low 3

Clinical Decision-Making Algorithm

1. First-line options (safest for breastfeeding):

   • Penicillins (amoxicillin, amoxicillin/clavulanic acid) 2
   • Cephalosporins (cephalexin, ceftriaxone) 1, 5

2. Second-line options (safe but with specific considerations):

   • Macrolides (erythromycin, azithromycin) - avoid in first 13 days postpartum if possible 1, 6
   • Metronidazole 1

3. Use with caution (only when benefits outweigh risks):

   • Clindamycin (monitor infant for GI effects) 1
   • Rifampin (limited data but suggested as safe) 1

4. Avoid or limit use (unless no alternatives):

   • Tetracyclines (doxycycline) - limit to 3 weeks if necessary 1
   • Fluoroquinolones - use only when specifically indicated 1, 3

Important Considerations

• Most antibiotics expose breastfed infants to subtherapeutic concentrations, with the highest assessed exposure being metronidazole at 11% of infant therapeutic dose 4
• Continued breastfeeding during antibiotic treatment is generally recommended and does not pose significant risks to the infant 6
• The LactMed database by the National Institutes of Health is a valuable resource for checking specific antibiotic safety during lactation 1
• When treating infections in breastfeeding mothers, consider both the need to treat the maternal infection effectively and minimize potential risks to the infant 3