What is the treatment for breastfeeding mastitis?

Treatment of Breastfeeding Mastitis

For breastfeeding mastitis, initiate a 1-2 day trial of conservative management with NSAIDs, ice application, and continued direct breastfeeding before prescribing antibiotics; if symptoms persist or worsen, start narrow-spectrum antibiotics targeting Staphylococcus aureus, with dicloxacillin 500 mg four times daily or cephalexin 500 mg four times daily as first-line agents. 1, 2

Initial Conservative Management (First 24-48 Hours)

• Start with supportive measures for 1-2 days, as most mastitis cases are inflammatory rather than truly infectious 2
• Administer NSAIDs for pain and inflammation control 1, 2
• Apply ice to the affected breast 1, 2
• Encourage continued direct breastfeeding from the affected breast, as regular milk removal is essential for resolution 1, 3, 4
• Minimize pumping, as overstimulation can worsen the condition 2
• Avoid aggressive breast massage and heat application, which may exacerbate inflammation 2

When to Initiate Antibiotic Therapy

Start antibiotics if symptoms do not improve within 24-48 hours of conservative management, or immediately if the patient presents with systemic symptoms such as fever and chills. 1, 2

First-Line Antibiotic Selection

Standard First-Line Options:

• Dicloxacillin 500 mg orally four times daily - the preferred agent for methicillin-susceptible S. aureus, which causes the majority of infectious mastitis 1
• Cephalexin 500 mg orally four times daily - equally effective alternative, particularly useful for penicillin-allergic patients 1

Alternative Antibiotics:

• Amoxicillin/clavulanic acid - broad-spectrum option that is safe during breastfeeding 1
• Erythromycin or azithromycin - for penicillin-allergic patients, but use with caution as there is a very low risk of infantile hypertrophic pyloric stenosis if used during the first 13 days of the infant's life 1

MRSA Coverage:

• Consider clindamycin if local MRSA prevalence is high, there is previous MRSA infection, or no response to first-line therapy 1, 3
• Use clindamycin cautiously as it may increase gastrointestinal side effects in the infant 1

Critical Management Principles

Continued Breastfeeding:

• Never discourage breastfeeding during mastitis treatment - continued feeding helps resolve the condition and does not pose risk to the infant 5, 1, 3, 4
• Breastfeeding can continue even if an abscess has formed, provided the infant's mouth does not contact purulent drainage 3
• Interrupting breastfeeding can worsen mastitis by causing breast engorgement, blocked ducts, or progression to abscess 5, 2

Antibiotic Safety in Breastfeeding:

• All recommended antibiotics (dicloxacillin, cephalexin, clindamycin) are compatible with breastfeeding, with minimal transfer to breast milk 1
• Beta-lactam antibiotics and first-generation cephalosporins are considered safe during lactation 1

Monitoring and Follow-Up

• Reassess within 48-72 hours if symptoms do not improve or worsen after starting antibiotics 1
• Perform ultrasonography to rule out abscess formation in patients with worsening or recurrent symptoms 1, 2
• Consider obtaining milk cultures to guide antibiotic therapy, especially in refractory cases 2
• Switch antibiotics based on culture results if initial therapy fails 1

Complications and Red Flags

Breast Abscess:

• Occurs in approximately 10% of mastitis cases 1, 3, 4
• Requires surgical drainage or needle aspiration once formed 1, 4
• Can be prevented by early treatment and continued breastfeeding 4

When to Hospitalize:

• Worsening symptoms despite appropriate outpatient management 3, 2
• Concern for sepsis or systemic involvement 3, 2
• Provide intravenous antibiotics and ensure access to breast pump if prolonged separation from infant occurs 3

Common Pitfalls to Avoid

• Do not advise expressing and discarding breast milk - this is illogical given that women are encouraged to breastfeed immediately after cesarean section when drug passage is actually higher 5
• Do not delay antibiotic therapy if conservative measures fail after 24-48 hours, as delay may lead to abscess formation 3, 2
• Do not recommend excessive pumping, heat application, or aggressive breast massage - these practices can worsen inflammation 2
• Do not assume all breast infections are simple mastitis - consider MRSA coverage in high-prevalence areas or treatment failures 1