Treatment of Mastitis
First-Line Antibiotic Therapy
For bacterial mastitis, initiate dicloxacillin or cephalexin as first-line antibiotics targeting Staphylococcus aureus, the most common causative organism. 1, 2, 3
Standard Antibiotic Regimens
For non-penicillin-allergic patients:
- Dicloxacillin: Standard dosing for serious infections is 150-300 mg every 6 hours orally 4
- Cephalexin: 500 mg orally every 6 hours (acceptable if no severe penicillin allergy) 1
- Both agents provide excellent coverage against S. aureus, which causes the majority of infectious mastitis cases 3, 4
For penicillin-allergic patients:
- Clindamycin: 300-450 mg three times daily orally 2, 5
- This is the preferred alternative, with activity against approximately 90% of S. pneumoniae isolates, though it has minimal transfer to breast milk 1
For MRSA concerns:
- Trimethoprim-sulfamethoxazole (TMP-SMX): 1-2 double-strength tablets twice daily 2
- Clindamycin (if susceptible): Same dosing as above 2
- Consider MRSA coverage in areas with high prevalence or in patients with risk factors 2
Duration of Treatment
Antibiotic therapy should continue for 5-10 days based on clinical response. 2 The evidence shows faster symptom clearance with antibiotics compared to supportive therapy alone, though the overall quality of evidence is limited 6.
Essential Conservative Management
Continue direct breastfeeding from the affected breast, as effective milk removal is the cornerstone of mastitis resolution. 1, 7
Key Conservative Measures (First 1-2 Days)
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation 7
- Ice application to reduce swelling 7
- Direct feeding from the affected breast rather than pumping 7
- Minimize pumping, as overstimulation can worsen inflammation 7
- Avoid aggressive breast massage and heat application, which may exacerbate tissue trauma 7
If symptoms do not improve within 1-2 days of conservative management, initiate antibiotic therapy. 7 This approach recognizes that most mastitis cases are inflammatory rather than truly infectious 7.
Safety of Breastfeeding During Treatment
Breastfeeding from the affected breast is safe during antibiotic treatment and serves as an adjunct to therapy. 1 The only contraindication is if the infant's mouth would contact purulent drainage from an abscess 1.
- Transfer of dicloxacillin/cloxacillin to breast milk is minimal 1, 4
- Continued breastfeeding does not pose risk to the infant and helps resolve the condition 1, 3
Monitoring for Complications
Approximately 10% of mastitis cases progress to breast abscesses, which require drainage when conservative and antibiotic therapy fail. 1
When to Consider Abscess
- Worsening symptoms despite appropriate antibiotic therapy 7
- Recurrent symptoms 7
- Immunocompromised patients 7
- Perform ultrasonography in these scenarios to identify abscess formation 7
Abscess Management
- Surgical drainage or needle aspiration is required once an abscess develops 3
- Breastfeeding can usually continue even with a treated abscess 3
Clinical Pitfalls to Avoid
Do not rely on oral antibiotics in patients with severe illness, nausea, vomiting, or signs of sepsis—these patients require intravenous antibiotics and hospital admission. 8, 7
Avoid excessive pumping and aggressive breast massage, as these practices overstimulate milk production and cause tissue trauma, potentially worsening mastitis. 7
Consider obtaining milk cultures to guide antibiotic therapy, particularly in cases not responding to initial treatment or in areas with high MRSA prevalence. 3, 7