What is the recommended management for non-purulent mastitis?

Management of Non-Purulent Mastitis

Non-purulent mastitis should be managed initially with a 1-2 day trial of conservative measures including NSAIDs, ice application, continued breastfeeding from the affected breast, and minimizing pumping, with narrow-spectrum antibiotics reserved only if symptoms fail to improve. 1

Initial Conservative Management (First-Line Approach)

Conservative therapy should be attempted first because most mastitis cases represent inflammation rather than true infection. 1

• Continue breastfeeding or milk expression regularly from the affected breast, as this is essential for treatment and prevents worsening of the condition 2, 1, 3
• Apply ice to the affected area for symptomatic relief 1
• Administer NSAIDs for pain management, as pain control is essential and can prevent symptom exacerbation 2, 1
• Minimize pumping rather than attempting to "empty" the breast, as overstimulation of milk production increases mastitis risk 1
• Avoid heat application and aggressive breast massage, as tissue trauma from these practices can worsen the condition 1

When to Escalate to Antibiotic Therapy

If symptoms do not improve after 1-2 days of conservative management, initiate narrow-spectrum antibiotics targeting common skin flora. 1

• First-line antibiotics should cover Staphylococcus and Streptococcus species (e.g., dicloxacillin, cephalexin) 2, 3
• Consider obtaining milk cultures to guide antibiotic selection, particularly if symptoms are severe or recurrent 1
• Most patients can be treated as outpatients with oral antibiotics 1

Indications for Hospitalization and IV Antibiotics

Hospital admission with intravenous antibiotics is warranted if the condition worsens or there is concern for sepsis. 2, 1

• Presence of fever and chills indicates systemic involvement requiring close monitoring 2
• Hospitalization should be considered for worsening symptoms despite oral antibiotics 2
• During hospitalization, provide access to breast pumps if prolonged separation from infant occurs to prevent worsening mastitis 2

Monitoring for Complications

Approximately 10% of mastitis cases progress to breast abscesses, which require drainage. 2, 3

• Perform ultrasonography to identify abscesses in immunocompromised patients or those with worsening or recurrent symptoms 1
• Breastfeeding can continue on the affected side even if an abscess has formed, provided the infant's mouth does not contact purulent drainage 2, 3
• Early treatment prevents abscess formation; delaying treatment of non-responsive cases increases this risk 2, 3

Common Pitfalls to Avoid

• Do NOT recommend frequent overfeeding, excessive pumping, heat application, or aggressive breast massage, as these practices worsen mastitis by overstimulating milk production and causing tissue trauma 1
• Do NOT discontinue breastfeeding, as this can worsen the condition 2
• Probiotics are not supported by good evidence for treatment or prevention 1
• Ensure proper lactation technique and good infant latch as the best prevention strategy 1, 3

Special Considerations for Non-Lactational Mastitis

For non-puerperal (non-lactational) mastitis, which is less common but clinically relevant:

• Prolactin-inhibiting drugs (e.g., bromocriptine) may be effective therapy and can result in lower abscess rates with long-term use preventing recurrence 4
• Consider hormonal factors and pre-existing breast lesions in the pathogenesis 4