What is the recommended treatment for mastitis in breastfeeding mothers?

Treatment of Mastitis in Breastfeeding Mothers

First-line antibiotic therapy for mastitis should be cephalexin or dicloxacillin, which are safe during breastfeeding and effective against Staphylococcus aureus, the most common causative organism. 1, 2

Initial Management Approach

Conservative measures should be attempted first for 24-48 hours before initiating antibiotics, as most mastitis cases are inflammatory rather than infectious 3:

• Continue breastfeeding from the affected breast - this does not pose risk to the infant and helps resolve the condition through effective milk removal 1, 2
• Use NSAIDs for pain and inflammation - these are compatible with breastfeeding for short-term use 4, 3
• Apply ice to the affected area (not heat, which can worsen inflammation) 3
• Minimize pumping - excessive pumping can overstimulate milk production and worsen symptoms 3

Antibiotic Therapy

Initiate antibiotics if symptoms do not improve within 24-48 hours or if the patient presents with severe symptoms 3:

First-Line Options:

• Cephalexin (cephalosporin) - generally considered safe during breastfeeding 1
• Dicloxacillin - minimal transfer to breast milk (relative infant dose only 0.03%) and effective against S. aureus 5, 6

Alternative Options:

• Amoxicillin/clavulanic acid - broad-spectrum option safe during breastfeeding 1, 4
• Clindamycin - for penicillin-allergic patients, though exercise caution as it may increase GI side effects in infants 7, 2
• Erythromycin or azithromycin - for penicillin-allergic patients, but note very low risk of infantile hypertrophic pyloric stenosis if exposed during first 13 days of breastfeeding 1, 4

MRSA Considerations

Consider coverage for methicillin-resistant S. aureus (MRSA) if 1:

• High local MRSA prevalence
• Previous MRSA infection
• No response to first-line therapy within 48-72 hours

Critical Follow-Up

Reevaluate within 48-72 hours if symptoms worsen or fail to improve 1:

• Perform ultrasonography to rule out breast abscess - the most common complication occurring in approximately 10% of mastitis cases 1, 2
• Consider milk culture to guide antibiotic selection if initial therapy fails 1, 3
• If abscess is present, surgical drainage or needle aspiration is required, though breastfeeding can usually continue 2

Common Pitfalls to Avoid

• Do not recommend heat application or aggressive breast massage - these worsen inflammation by overstimulating milk production 3
• Do not advise stopping breastfeeding - continued feeding from the affected breast is therapeutic and safe for the infant 1, 2
• Do not routinely use probiotics - not supported by good evidence 3
• Do not delay antibiotic therapy if patient has systemic symptoms (fever, malaise) or severe presentation - these patients may require immediate treatment rather than conservative trial 3