Treatment of Mastitis
For bacterial mastitis, initiate first-line antibiotic therapy with dicloxacillin or cloxacillin (flucloxacillin) targeting Staphylococcus aureus, while continuing breastfeeding to facilitate resolution. 1
Initial Conservative Management (1-2 Days)
Most mastitis cases are inflammatory rather than infectious, warranting a trial of conservative measures before antibiotics 2:
- Administer NSAIDs for pain and inflammation 2
- Apply ice to the affected breast 2
- Continue direct breastfeeding from the affected breast, as effective milk removal is essential for resolution 3, 4
- Minimize pumping to avoid overstimulation of milk production 2
- Avoid aggressive breast massage and heat application, as these may worsen the condition 2
Antibiotic Therapy Indications
Initiate antibiotics if symptoms do not improve within 24-48 hours of conservative management 2, 5:
First-Line Antibiotic Options
- Dicloxacillin or cloxacillin (flucloxacillin): Targets Staphylococcus aureus, the most common causative organism 1
- Cephalexin 500 mg orally every 6 hours: For patients with non-severe penicillin allergy 1
- Cephradine: Alternative first-generation cephalosporin with comparable efficacy to amoxicillin 6
Duration and Route
- Oral antibiotics are sufficient for most patients treated as outpatients 2
- Consider milk cultures to guide antibiotic selection, particularly in refractory cases 2
Breastfeeding During Treatment
Mothers should continue breastfeeding during antibiotic treatment 3, 1, 4:
- Breastfeeding from the affected breast is safe unless the infant's mouth would contact purulent drainage from an abscess 3, 4
- Antibiotic transfer to breast milk is minimal with dicloxacillin/cloxacillin 1
- Regular feeding or milk expression serves as an adjunct to antibiotic therapy 3
Monitoring for Complications
Approximately 10% of mastitis cases progress to breast abscesses requiring drainage 3, 4:
- Perform ultrasonography in immunocompromised patients or those with worsening/recurrent symptoms 2
- Consider hospital admission with IV antibiotics if the patient develops sepsis or severe systemic symptoms 2
- Abscess drainage is required when conservative and antibiotic therapy fail 3
When to Escalate Care
- Worsening symptoms despite 24 hours of antibiotics warrants imaging and consideration of abscess formation 5
- Recurrent mastitis should prompt evaluation for underlying causes and consideration of milk culture 2
- Systemic signs of sepsis require immediate IV antibiotics and hospitalization 2
Common Pitfalls to Avoid
- Do not recommend excessive pumping or "emptying the breast", as overstimulation worsens mastitis 2
- Do not apply heat or perform aggressive massage, which can exacerbate inflammation 2
- Do not delay antibiotics beyond 24-48 hours if conservative measures fail 5
- Probiotics lack sufficient evidence for treatment or prevention 2