What is the treatment for mastitis puerperal?

Treatment of Puerperal Mastitis

Continue breastfeeding or milk expression on the affected breast while initiating antibiotics that cover Staphylococcus aureus, specifically dicloxacillin or cephalexin as first-line agents, and drain any abscesses that develop. 1, 2

Immediate Management Priorities

Continue Breastfeeding

• Regular feeding or milk expression from the affected breast is essential and must be encouraged - discontinuing breastfeeding worsens the condition and increases risk of abscess formation 1, 2, 3
• Breastfeeding can safely continue even if an abscess has formed, provided the infant's mouth does not contact purulent drainage from the breast 1, 2
• Complete emptying of the breast reduces risk of progression and is therapeutic 2
• No ill effects occur in infants who continue nursing from the affected breast 3

Antibiotic Therapy

• Start antibiotics effective against Staphylococcus aureus: dicloxacillin or cephalexin are first-line choices 2
• Cephalosporins are appropriate empiric therapy based on expected pathogens 4
• If no improvement occurs within 24 hours of conservative measures, antibiotics must be initiated 4
• Consider methicillin-resistant S. aureus (MRSA) coverage if patient fails initial therapy, as MRSA now accounts for up to 64% of S. aureus isolates in puerperal mastitis 5
• For suspected MRSA, use antibiotics effective against this organism (e.g., trimethoprim-sulfamethoxazole, clindamycin) 5

Pain Management

• Provide appropriate analgesics, as pain control is essential and can prevent symptom exacerbation 1

Management of Complications

Breast Abscess

• Approximately 10% of mastitis cases progress to breast abscess 1, 2
• Abscesses require drainage - either surgical drainage or needle aspiration 2
• Under antibiotic coverage, abscesses can be punctured rather than requiring open surgical drainage in most cases 4
• Surgical intervention with incision and drainage is reserved for cases where needle aspiration fails 4
• Patients requiring incision and drainage typically have longer duration of symptoms before treatment, longer hospitalizations, and higher rates of MRSA infection 5
• Breastfeeding can continue even after abscess drainage, as long as the infant avoids contact with purulent drainage 1, 2

Key Clinical Pitfalls

Timing of Antibiotic Initiation

• Early antibiotic therapy prevents abscess formation 3
• Delaying treatment of non-responsive cases leads to abscess development 1
• The 24-hour window is critical - if conservative measures don't improve symptoms, antibiotics are mandatory 4

Breastfeeding Discontinuation

• Never advise stopping breastfeeding - this is a common error that worsens outcomes 1, 3
• Patients who undergo incision and drainage are more likely to discontinue breastfeeding, but this should be discouraged unless absolutely necessary 5
• Bromocriptine for lactation suppression is not suitable if the mother wishes to continue breastfeeding 4

MRSA Considerations

• MRSA has emerged as a dominant pathogen over the past decade, accounting for 64% of S. aureus isolates in hospitalized patients 5
• Failure to improve on standard anti-staphylococcal antibiotics should prompt consideration of MRSA and antibiotic adjustment 5