What is the treatment for mastitis puerperal?

Treatment of Puerperal Mastitis

Continue breastfeeding or milk expression on the affected breast while initiating antibiotic therapy targeting Staphylococcus aureus, with dicloxacillin or cephalexin as first-line agents. 1, 2

Immediate Management Priorities

Continue Breastfeeding

• Regular feeding or milk expression is essential and must be encouraged even during active mastitis. 1
• Breastfeeding can safely continue on the affected side, even if an abscess has formed, provided the infant's mouth does not contact purulent drainage from the breast. 1
• Discontinuing breastfeeding worsens the condition and increases risk of abscess formation. 1
• Complete breast emptying reduces the risk of progression and is a cornerstone of treatment. 2

Antibiotic Therapy

• Initiate antibiotics targeting Staphylococcus aureus as the primary pathogen. 2
• First-line agents: dicloxacillin or cephalexin (both effective against S. aureus). 2
• Alternative: cephalosporins (cephradine) if penicillin allergy or intolerance. 3, 4
• If symptoms do not improve within 24 hours of conservative measures, antibiotics must be introduced. 3

Emerging Resistance Considerations

• As methicillin-resistant S. aureus (MRSA) becomes more common in puerperal mastitis, consider antibiotics effective against MRSA if initial therapy fails or if there is known MRSA colonization in mother or infant. 2, 5
• CA-MRSA puerperal mastitis is an emerging problem in Europe with potential for cross-infection between mother and child. 5

Supportive Care Measures

Pain Management

• Appropriate analgesics are essential, as pain can exacerbate symptoms. 1
• Pain medication should not be withheld and is a mainstay of treatment alongside antibiotics and milk removal. 4

Optimize Breastfeeding Technique

• Work with a lactation consultant to correct poor latch or positioning issues that precipitate mastitis. 2
• Address sore nipples, which can precipitate mastitis, by evaluating for mechanical irritation, infant mouth anomalies (cleft palate), or bacterial/yeast infection. 2

Hospital Environment Support

• Provide a breast pump if prolonged separation occurs to reduce risk of worsening mastitis. 6
• Ensure access to trained breastfeeding support staff. 6
• Schedule procedures to allow breastfeeding or milk expression as close to surgery as possible if hospitalization is required. 6

Management of Complications

Breast Abscess

• Approximately 10% of mastitis cases progress to breast abscesses, which require drainage. 1
• Abscess management options:
  • Needle aspiration under antibiotic coverage. 3
  • Surgical drainage only in exceptional cases where aspiration fails. 3, 2
• Breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage. 1
• Early treatment of mastitis and continued breastfeeding prevent abscess formation. 2

Common Pitfalls to Avoid

• Do not advise stopping breastfeeding – this worsens the condition and delays resolution. 1
• Do not delay antibiotic therapy beyond 24 hours if conservative measures (improved positioning, frequent feeding) fail to improve symptoms. 3
• Do not use bromocriptine if the mother wishes to continue breastfeeding. 3
• Do not rely on oral antibiotics alone in severely ill patients with nausea, vomiting, or signs of systemic toxicity. 7

Antibiotic Dosing Considerations

• Dicloxacillin should be taken on an empty stomach (one hour before meals or two hours after eating) for optimal absorption. 7
• Patients must complete the entire course of therapy even if symptoms resolve early. 7
• Monitor for allergic reactions: shortness of breath, wheezing, skin rash, or severe diarrhea warrant immediate discontinuation and physician notification. 7

Special Populations

Candida Mastitis

• In rare cases of suspected candida infection, nystatin is the first-choice treatment. 3
• Consider fungal etiology if symptoms persist despite appropriate antibacterial therapy or if there is concurrent infant oral thrush. 3