What is the treatment for mastitis, especially when caused by a bacterial infection?

Treatment of Mastitis

First-line antibiotic therapy for bacterial mastitis should be dicloxacillin or cephalexin, targeting Staphylococcus aureus, while continuing direct breastfeeding from the affected breast. 1, 2

Initial Conservative Management (First 24-48 Hours)

Before initiating antibiotics, a 1-2 day trial of conservative measures is appropriate since most mastitis cases are inflammatory rather than infectious 3:

• Continue direct breastfeeding from the affected breast as effective milk removal is essential for resolution 1
• Use NSAIDs for pain control and ice application 3
• Minimize pumping and avoid overstimulation of milk production 3
• Avoid aggressive breast massage and heat application, as these may worsen the condition 3

Antibiotic Therapy Indications

Initiate antibiotics if symptoms do not improve after 24-48 hours of conservative management, or if the patient presents with severe symptoms initially 3.

First-Line Antibiotic Options

For patients without penicillin allergy:

• Dicloxacillin: Most commonly recommended first-line agent targeting S. aureus 1, 2, 4
• Cephalexin 500 mg orally every 6 hours: Alternative first-line option 1, 2
• Duration: 5-10 days based on clinical response 2

For penicillin-allergic patients:

• Clindamycin 300-450 mg orally three times daily 2, 5
• Transfer to breast milk is minimal, allowing continued breastfeeding 5

MRSA Coverage

When MRSA is suspected or confirmed:

• Trimethoprim-sulfamethoxazole (TMP-SMX): 1-2 double-strength tablets twice daily 2
• Clindamycin (if susceptible): 300-450 mg three times daily 2

Breastfeeding During Treatment

• Breastfeeding from the affected breast is safe and should continue during antibiotic therapy 1, 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
• Dicloxacillin/cloxacillin transfer to breast milk is minimal 4

Monitoring and Complications

• Approximately 10% of mastitis cases progress to breast abscesses requiring drainage 1
• If symptoms worsen or fail to improve after 48-72 hours of antibiotics, obtain ultrasonography to evaluate for abscess formation 3
• Consider milk cultures to guide antibiotic therapy, particularly in recurrent cases or when MRSA is suspected 3
• Abscess drainage (surgical or needle aspiration) is required when conservative and antibiotic therapy fail 1

Common Pitfalls to Avoid

• Do not recommend excessive pumping to "empty the breast" - this overstimulates milk production and may worsen mastitis 3
• Avoid heat application and aggressive breast massage - these are no longer recommended as they may exacerbate the condition 3
• Do not delay antibiotics beyond 48 hours if conservative measures fail, as this increases abscess risk 6
• Do not advise cessation of breastfeeding - continued feeding is therapeutic and safe for the infant 1, 6