Treatment of Postpartum Mastitis with Fever and Chills
For a postpartum patient with mastitis presenting with fever and chills, initiate a 1-2 day trial of conservative management with NSAIDs, ice application, and continued direct breastfeeding, followed by narrow-spectrum oral antibiotics targeting Staphylococcus aureus (such as dicloxacillin or cephalexin) if symptoms do not improve, with hospital admission and IV antibiotics reserved for worsening symptoms or concern for sepsis. 1
Initial Conservative Management (First 1-2 Days)
Most mastitis cases are inflammatory rather than infectious, making conservative measures the appropriate first-line approach 1:
- Continue breastfeeding or milk expression on the affected breast, as regular milk removal is essential for treatment 2, 1
- Administer NSAIDs for pain management, as pain can exacerbate symptoms 2
- Apply ice to the affected breast 1
- Feed the infant directly from the breast rather than pumping when possible 1
- Minimize pumping, as overstimulation of milk production increases mastitis risk 1
Critical pitfall to avoid: Do not recommend frequent overfeeding, excessive pumping to "empty" the breast, heat application, or aggressive breast massage—these practices worsen the condition by overstimulating milk production and causing tissue trauma 1.
Antibiotic Therapy (If No Improvement After 1-2 Days)
When conservative measures fail, antibiotic therapy becomes necessary 1:
Outpatient Oral Antibiotics
- Prescribe narrow-spectrum antibiotics effective against Staphylococcus aureus and Streptococcus species 1, 3
- Preferred agents: Dicloxacillin or cephalexin 3
- Alternative consideration: As methicillin-resistant S. aureus becomes more prevalent, antibiotics effective against MRSA may be needed 3
Inpatient IV Antibiotics
Admit for IV antibiotics if: 1
- Symptoms worsen despite oral antibiotics
- Concern for sepsis (fever with chills suggests systemic involvement) 4
- Immunocompromised status 1
The presence of fever and chills in your patient indicates systemic involvement and warrants close monitoring 4. While most patients can be managed as outpatients, the severity of systemic symptoms should guide the decision for hospitalization 1.
Diagnostic Considerations
- Obtain milk cultures to guide antibiotic therapy, particularly if symptoms are severe or not responding to initial treatment 1
- Perform breast ultrasound if the patient is immunocompromised or has worsening/recurrent symptoms to identify abscess formation 1
- Clinical diagnosis is sufficient in most cases—laboratory tests and imaging are not routinely needed 1
Management of Complications
Approximately 10% of mastitis cases progress to breast abscesses, which require drainage 2:
- Abscess drainage: Surgical drainage or needle aspiration is necessary once an abscess forms 3, 5
- Continue breastfeeding even with a treated abscess, provided the infant's mouth does not contact purulent drainage 2, 3
- Early treatment prevents abscess formation: Delaying treatment of non-responsive cases increases abscess risk 2
Supportive Hospital Care (If Admitted)
For hospitalized patients 2:
- Provide access to a breast pump if prolonged separation from infant occurs
- Ensure availability of trained breastfeeding support staff
- Schedule procedures to allow breastfeeding or milk expression as close to surgery as possible
Evidence Quality Note
While the American Academy of Pediatrics and recent guidelines strongly support continued breastfeeding and conservative management followed by antibiotics 2, 1, a Cochrane review found insufficient high-quality evidence to definitively confirm antibiotic effectiveness 6. However, clinical practice and expert consensus support this approach, with one older study suggesting faster symptom clearance with antibiotics 6.