Treatment of Mastitis
For bacterial mastitis, initiate dicloxacillin or cloxacillin as first-line antibiotic therapy targeting Staphylococcus aureus, while continuing direct breastfeeding from the affected breast to ensure effective milk removal. 1
Initial Conservative Management (First 24-48 Hours)
Before starting antibiotics, attempt a 1-2 day trial of conservative measures, as most mastitis cases are inflammatory rather than infectious 2:
- Continue direct breastfeeding from the affected breast as effective milk removal is essential for resolution 1
- Use NSAIDs for pain and inflammation control 2
- Apply ice to reduce swelling 2
- Avoid excessive pumping, heat application, and aggressive breast massage, as these worsen the condition by overstimulating milk production and causing tissue trauma 2
When to Initiate Antibiotic Therapy
Start antibiotics if symptoms do not improve within 24-48 hours of conservative management, or if the patient presents with severe symptoms (high fever, systemic illness) 2.
First-Line Antibiotic Selection
Dicloxacillin or cloxacillin (flucloxacillin) are the recommended first-line agents because they target Staphylococcus aureus, the most common bacterial cause 1, 3, 4:
- These agents have minimal transfer to breast milk 1, 4
- Most bacterial mastitis is caused by S. aureus resistant to beta-lactamase sensitive antibiotics 4
Alternative Antibiotics for Penicillin Allergy
For patients with non-severe penicillin allergy, use cephalexin 500 mg orally every 6 hours 1.
For patients with severe Type I hypersensitivity reactions to penicillin, alternative agents are needed, though specific recommendations require consideration of local resistance patterns 3.
Role of Milk Cultures
Obtain milk cultures to determine the infecting organism and antibiotic sensitivity, particularly in cases not responding to initial therapy 4. This is increasingly important as methicillin-resistant S. aureus (MRSA) becomes more common and may require different antibiotic coverage 3.
Breastfeeding During Treatment
Breastfeeding from the affected breast is safe and should continue during antibiotic treatment 1, 3, 4:
- The only exception is if the infant's mouth would contact purulent drainage from an abscess 1
- Regular feeding or milk expression serves as an adjunct to antibiotic therapy 1
- Continued breastfeeding helps resolve the condition and does not pose risk to the infant 1
Monitoring for Complications
Approximately 10% of mastitis cases progress to breast abscesses 1:
- Perform ultrasonography if symptoms worsen, recur, or fail to improve with conservative and antibiotic therapy 2
- Consider imaging in immunocompromised patients 2
- Abscess drainage (surgical or needle aspiration) is required when conservative and antibiotic therapy fail 1, 3
- Breastfeeding can usually continue even with a treated abscess 3
Common Pitfalls to Avoid
Do not recommend excessive pumping, heat application, or aggressive breast massage, as these practices increase risk by overstimulating milk production and causing tissue trauma 2. The outdated practice of "emptying the breast" through pumping may actually worsen the condition 2.
Do not use probiotics for treatment or prevention, as they are not supported by good evidence 2.
Inpatient Management
Consider hospital admission with intravenous antibiotics if the patient develops worsening symptoms or signs of sepsis 2.