What is the treatment for mastitis (inflammation of breast tissue) after breastfeeding?

Treatment of Mastitis After Breastfeeding

First-line antibiotic therapy for lactational mastitis should be dicloxacillin 500 mg orally four times daily or cephalexin 500 mg orally four times daily, targeting methicillin-susceptible Staphylococcus aureus, while continuing breastfeeding to facilitate resolution. 1, 2

Initial Conservative Management (24-48 Hours)

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

• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation 3
• Ice application to the affected breast 3
• Direct breastfeeding from the affected breast rather than pumping 3
• Minimize pumping, as overstimulation worsens inflammation 3

Critical pitfall to avoid: Do NOT use heat application, aggressive breast massage, or excessive pumping to "empty the breast"—these practices worsen mastitis by increasing tissue trauma and overstimulating milk production 3.

Antibiotic Therapy Indications

Initiate antibiotics if 3:

• No improvement after 24-48 hours of conservative management
• Severe symptoms at presentation
• Signs of systemic infection (high fever, malaise)

First-Line Antibiotic Selection

For methicillin-susceptible S. aureus (most common cause):

• Dicloxacillin 500 mg orally four times daily (preferred by Infectious Diseases Society of America) 1
• Cephalexin 500 mg orally four times daily (equally effective alternative, especially for penicillin-allergic patients) 1, 2

Both antibiotics are safe during breastfeeding with minimal transfer to breast milk 1, 4.

Alternative Antibiotics for Special Circumstances

For penicillin-allergic patients:

• Erythromycin or azithromycin are acceptable alternatives 1
• Important caveat: Very low risk of infantile hypertrophic pyloric stenosis if macrolides are used during the first 13 days of infant life; generally safe after this period 1, 4

For suspected or confirmed MRSA (consider if):

• High local MRSA prevalence 1
• Previous MRSA infection 1
• No response to first-line therapy after 48-72 hours 1
• Treatment: Clindamycin, though use with caution as it may increase GI side effects in the infant 1

Broad-spectrum option:

• Amoxicillin/clavulanic acid is safe during breastfeeding based on limited human data 1, 5

Critical Management Principles

Continue breastfeeding throughout treatment:

• Continued breastfeeding is essential for mastitis resolution and does not pose risk to the infant 1, 4, 2
• Breastfeed even on the affected breast, as long as the infant's mouth does not contact purulent drainage if an abscess has developed 4
• Regular breast emptying through continued breastfeeding prevents complications 1, 4

Premature cessation of breastfeeding causes more harm, including risks of breast engorgement, blocked ducts, formula intolerance, and loss of breastfeeding's protective benefits 4.

Monitoring and Follow-Up

Reevaluate within 48-72 hours if:

• Symptoms worsen 1
• No improvement with antibiotic therapy 1
• Action: Perform ultrasonography to rule out breast abscess 1, 3

Obtain milk cultures to guide antibiotic therapy, particularly in immunocompromised patients or those with recurrent symptoms 3.

Complications

Breast abscess is the most common complication, occurring in approximately 10% of mastitis cases 1, 2:

• Prevented by early treatment and continued breastfeeding 2
• Once present, requires surgical drainage or needle aspiration 2
• Breastfeeding can usually continue even with a treated abscess 2

What NOT to Do

• Avoid fluoroquinolones and tetracyclines during breastfeeding due to potential impacts on infant development 1
• Do not recommend probiotics—not supported by good evidence for treatment or prevention 3
• Do not advise heat application or aggressive breast massage—these worsen inflammation 3
• Do not encourage excessive pumping—this overstimulates milk production and worsens symptoms 3