What is the recommended treatment for mastitis?

Treatment of Mastitis

Immediate Treatment Approach

For lactational mastitis, begin with a 1-2 day trial of conservative management including NSAIDs, ice application, and continued breastfeeding before initiating antibiotics; for non-lactational mastitis in non-breastfeeding women, start empiric antibiotics immediately targeting Staphylococcus aureus. 1, 2

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Lactational Mastitis Management Algorithm

First-Line Conservative Management (Days 1-2)

• Continue breastfeeding or milk expression from the affected breast - this is essential for treatment and stopping will worsen the condition 3, 2, 4
• Administer NSAIDs for pain and inflammation 2
• Apply ice to the affected area 1, 2
• Minimize pumping and avoid overstimulation, as excessive pumping and breast massage can worsen mastitis 2
• Ensure proper infant latch and positioning to prevent recurrence 4, 5

Antibiotic Therapy (If No Improvement After 1-2 Days)

Initiate narrow-spectrum antibiotics targeting Staphylococcus aureus and Streptococcus species: 2, 4

• First-line agents: Dicloxacillin 500 mg every 6 hours OR Cephalexin 1, 4, 5
• Dicloxacillin transfers minimally into breast milk (relative infant dose 0.03%) and is safe for continued breastfeeding 6
• Consider obtaining milk cultures to guide therapy, especially if symptoms worsen or recur 2
• As methicillin-resistant S. aureus becomes more prevalent, antibiotics effective against MRSA may be needed 4

When to Escalate Care

• Hospitalize if: Worsening symptoms despite oral antibiotics, concern for sepsis, or systemic involvement with fever and chills 3, 2
• Intravenous antibiotics are required for severe cases 2
• Continue breastfeeding even during hospitalization; provide breast pump if prolonged separation occurs 3

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Non-Lactational Mastitis (Non-Breastfeeding Women)

Immediate Antibiotic Therapy

Do not delay antibiotics in non-breastfeeding women with inflammatory signs - start empiric therapy immediately: 1

• First-line agents: Dicloxacillin OR Cephalexin targeting Staphylococcus aureus 1
• Combine with NSAIDs and ice application 1
• Non-lactational mastitis is more likely infectious from the outset and requires prompt treatment 1

Critical Red Flags - Exclude Inflammatory Breast Cancer

Urgent evaluation is mandatory if any of the following are present: 1

• Erythema occupying ≥1/3 of breast surface 1
• Peau d'orange (orange-peel skin texture) 1
• Symptoms persisting >1 week despite appropriate antibiotics 1
• History of recurrent "mastitis" not responding to antibiotics 1
• Bloody nipple discharge 1

If inflammatory breast cancer is suspected: 1

• Perform urgent ultrasound within 24-48 hours 1
• If mass detected, obtain core needle biopsy within 48 hours 1
• Perform punch biopsy of skin, diagnostic mammogram with ultrasound 1
• Arrange multidisciplinary oncology referral within 24-48 hours 1
• Critical pitfall: A benign skin punch biopsy does not rule out malignancy - comprehensive evaluation is essential 1

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Abscess Management

Detection and Treatment

• Approximately 10% of mastitis cases progress to abscess formation 1, 2, 4
• Perform ultrasonography in patients with worsening symptoms, recurrent mastitis, or immunocompromised status 1, 2
• Once abscess forms, surgical drainage or needle aspiration is required 1, 4
• Breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage 3, 4

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Key Clinical Pitfalls to Avoid

• Do not discontinue breastfeeding - this worsens mastitis and increases abscess risk 3, 2
• Avoid excessive pumping, heat application, and aggressive breast massage - these worsen inflammation through overstimulation 2
• Do not delay antibiotics in non-lactational mastitis - it is infectious from onset 1
• Do not assume all breast pain is mastitis - differential includes Mondor disease, costochondritis, chest wall pain, trauma, and inflammatory breast cancer 1
• Do not ignore persistent symptoms >1 week on antibiotics - this may indicate inflammatory breast cancer with significantly worse mortality if diagnosis is delayed 1

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Special Considerations

Non-Lactational Mastitis Underlying Pathology

• More commonly occurs in subareolar area or nipple region 1
• Often associated with duct ectasia and periductal inflammation, linked to heavy smoking 1
• In women >50 years, evaluation to exclude malignancy is essential 1

Probiotics

• Use of probiotics for treatment or prevention is not supported by good evidence 2