What is the treatment for mastitis?

Treatment of Mastitis

For lactational mastitis, begin with a 1-2 day trial of conservative management including NSAIDs, ice application, and continued breastfeeding from the affected breast; only initiate antibiotics targeting Staphylococcus aureus (such as dicloxacillin or cephalexin) if symptoms fail to improve. 1

Initial Conservative Management (First-Line Approach)

Most cases of mastitis are inflammatory rather than infectious, making conservative measures the appropriate initial treatment 1:

• Continue breastfeeding or milk expression from the affected breast - this is essential for treatment and should never be discontinued, as stopping worsens the condition 2, 1
• Administer NSAIDs for pain control - pain management is critical as pain exacerbates symptoms 2
• Apply ice to the affected area 1
• Minimize pumping - excessive pumping overstimulates milk production and worsens inflammation 1
• Avoid heat application and aggressive breast massage - these increase tissue trauma and worsen the condition 1

The 2024 American Family Physician rapid evidence review represents the most current guidance, emphasizing that conservative management for 1-2 days is often sufficient before escalating to antibiotics 1. This contrasts with older approaches that immediately initiated antibiotics.

Antibiotic Therapy (Second-Line)

If symptoms do not improve after 1-2 days of conservative management, initiate antibiotics 1:

• First-line antibiotics: Dicloxacillin or cephalexin - these target Staphylococcus aureus and common skin flora 3, 1
• Consider obtaining milk cultures to guide antibiotic selection, particularly in refractory cases 1
• Monitor for MRSA: As methicillin-resistant S. aureus becomes more prevalent, antibiotics effective against this organism may be needed 3

The evidence for antibiotics remains limited - a Cochrane review found insufficient evidence to confirm their effectiveness, though clinical practice and expert consensus support their use when conservative measures fail 2, 4.

Inpatient Management

Hospitalization is indicated when 2, 1:

• Fever and chills with systemic involvement suggest potential sepsis and warrant close monitoring 2
• Symptoms worsen despite oral antibiotics - transition to intravenous antibiotics 1
• Provide breast pump access if prolonged mother-infant separation occurs 2
• Ensure access to lactation support staff during hospitalization 2

Management of Complications

Breast abscess develops in approximately 10% of mastitis cases 2, 3:

• Obtain ultrasonography in immunocompromised patients or those with worsening/recurrent symptoms to identify abscesses 1
• Drainage is required - either surgical drainage or needle aspiration 3
• Continue breastfeeding on the affected side as long as the infant's mouth does not contact purulent drainage 2, 3
• Early treatment of mastitis prevents abscess formation 3

Critical Pitfalls to Avoid

• Never discontinue breastfeeding - this worsens mastitis and increases abscess risk 2
• Avoid excessive pumping and "emptying the breast" - this overstimulates milk production and worsens inflammation 1
• Do not apply heat or perform aggressive breast massage - these cause tissue trauma 1
• Do not delay treatment in non-responsive cases, as this leads to abscess formation 2

Breastfeeding Technique Optimization

Address underlying mechanical issues with lactation consultant assistance 3:

• Ensure proper infant latch - poor latch causes nipple trauma that precipitates mastitis 3, 1
• Encourage physiologic breastfeeding rather than pumping when possible 1
• Evaluate for infant mouth anomalies (cleft palate) that may contribute to poor latch 3