What is the recommended treatment for mastitis in breastfeeding women?

Treatment of Mastitis in Breastfeeding Women

For breastfeeding women with mastitis, initiate a 1-2 day trial of conservative management with NSAIDs, ice application, and continued direct breastfeeding; if symptoms do not improve within 48-72 hours, start antibiotic therapy with cephalexin or dicloxacillin as first-line agents. 1, 2

Initial Conservative Management (First 24-48 Hours)

Most mastitis cases are inflammatory rather than infectious, making conservative measures the appropriate initial approach 2:

• Continue direct breastfeeding from the affected breast - this is safe for the infant and essential for resolution 1, 3, 2
• NSAIDs for pain and inflammation - compatible with breastfeeding for short-term use 4
• Ice application to reduce inflammation 2
• Minimize pumping - excessive pumping can worsen the condition by overstimulating milk production 2
• Avoid aggressive breast massage and heat application - these may worsen tissue trauma and inflammation 2

When to Initiate Antibiotics

Start antibiotics if 1, 2:

• No improvement after 24-48 hours of conservative management
• Worsening symptoms
• Systemic symptoms (fever, malaise) are severe at presentation
• High local prevalence of MRSA or previous MRSA infection

First-Line Antibiotic Selection

Cephalexin 500 mg orally four times daily is the preferred first-line agent 1:

• Effective against methicillin-susceptible Staphylococcus aureus, the most common causative organism 1, 3
• Safe during breastfeeding with minimal transfer to breast milk 1
• Appropriate alternative for penicillin-allergic patients 1

Dicloxacillin 500 mg orally four times daily is equally effective 1, 5:

• Oral agent of choice for methicillin-susceptible S. aureus 1
• Minimal transfer to breast milk (RID only 0.03%) 6
• Transfer to breast milk is negligible due to high plasma protein binding 5, 6

Amoxicillin/clavulanic acid is a broad-spectrum alternative 7, 1, 4:

• Safe during breastfeeding based on limited human data 7, 4
• Useful when broader coverage is needed 1

Alternative Antibiotics for Special Circumstances

For penicillin-allergic patients 7, 1, 4:

• Erythromycin or azithromycin are acceptable alternatives
• Important caveat: Very low risk of infantile hypertrophic pyloric stenosis if macrolides are used during the first 13 days of infant life 4
• Generally considered safe after this period 7

For suspected or confirmed MRSA 1:

• Consider MRSA coverage when local prevalence is high, previous MRSA infection exists, or no response to first-line therapy
• Clindamycin is an option, but use with caution as it may increase GI side effects in the infant 7, 1

Monitoring and Follow-Up

Reevaluate within 48-72 hours if 1, 2:

• Symptoms worsen or fail to improve
• This timing is critical to rule out breast abscess formation
• Consider obtaining milk cultures to guide antibiotic selection 1, 2
• Ultrasonography should be performed in immunocompromised patients or those with recurrent/worsening symptoms 2

Critical Management Principles

Continue breastfeeding throughout treatment 1, 3, 2:

• Breastfeeding does not pose risk to the infant
• Regular breast emptying through direct feeding helps resolve mastitis
• All recommended antibiotics are compatible with breastfeeding 1

Breast abscess prevention 3:

• Occurs in approximately 10% of mastitis cases if untreated 1, 3
• Prevented by early antibiotic treatment and continued breastfeeding 3
• If abscess develops, surgical drainage or needle aspiration is required, but breastfeeding can usually continue 3

Common Pitfalls to Avoid

• Do not recommend excessive pumping or "complete emptying" - this overstimulates milk production and worsens inflammation 2
• Do not apply heat or aggressive massage - these increase tissue trauma 2
• Do not discontinue breastfeeding - this is counterproductive and increases risk of abscess 1, 3
• Do not delay antibiotic therapy beyond 48-72 hours if conservative measures fail - this increases abscess risk 1, 2