What is the treatment for mastitis?

Treatment of Mastitis

Continue breastfeeding or milk expression and initiate a 1-2 day trial of conservative management with NSAIDs and ice application before starting antibiotics, unless systemic symptoms are severe. 1, 2

Initial Conservative Management (First 1-2 Days)

• Start with conservative measures for 24-48 hours as most mastitis cases are inflammatory rather than infectious 2
• Administer NSAIDs for pain control and anti-inflammatory effects 2
• Apply ice to the affected breast 2
• Continue breastfeeding directly from the affected breast - this is essential for treatment and should never be discontinued 1, 3, 2
• Feed the infant directly from the breast rather than pumping, as pumping may worsen the condition through overstimulation 2
• Minimize pumping and avoid excessive breast emptying attempts 2

Critical pitfall to avoid: Do not recommend frequent overfeeding, excessive pumping, heat application, or aggressive breast massage - these practices increase tissue trauma and milk production overstimulation, potentially worsening mastitis 2

Antibiotic Therapy (If No Improvement After Conservative Management)

• Initiate narrow-spectrum antibiotics if symptoms do not improve within 1-2 days of conservative treatment 2
• Target common skin flora, particularly Staphylococcus aureus and Streptococcus species 1, 3, 2
• Preferred oral antibiotics include:
  • Dicloxacillin 3
  • Cephalexin 3
• Consider obtaining milk cultures to guide antibiotic selection, especially in immunocompromised patients or those with recurrent symptoms 2
• Be aware that methicillin-resistant S. aureus (MRSA) is becoming more common and may require alternative antibiotic coverage 3

Evidence note: While a Cochrane review found insufficient high-quality evidence for antibiotics 4, clinical practice guidelines and expert consensus support their use when conservative measures fail, with one study showing faster symptom clearance 1

Indications for Hospitalization and IV Antibiotics

• Admit patients with fever, chills, and systemic involvement suggesting possible sepsis 1
• Provide IV antibiotics for worsening symptoms despite oral therapy 2
• Ensure access to breast pumps if prolonged separation from infant occurs 1
• Schedule procedures to allow continued breastfeeding or milk expression 1

Management of Breast Abscess

• Approximately 10% of mastitis cases progress to abscess formation 1, 3
• Perform ultrasound imaging in immunocompromised patients or those with worsening/recurrent symptoms to identify abscesses 2
• Abscesses require drainage via surgical incision or needle aspiration 3
• Breastfeeding can continue on the affected side even with a treated abscess, provided the infant's mouth does not contact purulent drainage 1, 3

Critical warning: Discontinuing breastfeeding worsens mastitis, and delaying treatment of non-responsive cases increases abscess risk 1

Supportive Measures Throughout Treatment

• Provide adequate pain management with analgesics, as pain exacerbates symptoms 1
• Optimize breastfeeding technique with lactation consultant assistance 3
• Address any mechanical issues such as poor infant latch or infant mouth anomalies 3
• Evaluate and treat sore nipples, which can precipitate mastitis 3

Evidence regarding probiotics: Current evidence does not support probiotic use for treatment or prevention of mastitis 2