What is the treatment for mastitis, especially when caused by a bacterial infection?

Treatment of Mastitis

For bacterial mastitis in breastfeeding women, first-line antibiotic therapy is dicloxacillin or cloxacillin (flucloxacillin), targeting Staphylococcus aureus, while continuing direct breastfeeding from the affected breast. 1

Initial Conservative Management (First 24-48 Hours)

Most mastitis cases are inflammatory rather than infectious, so begin with a 1-2 day trial of conservative measures before antibiotics: 2

• Continue direct breastfeeding from the affected breast - this is the most essential intervention for resolution through effective milk removal 1, 3
• NSAIDs for pain and inflammation 2
• Ice application to reduce swelling 2
• Minimize pumping - excessive pumping can worsen the condition through overstimulation 2

Avoid aggressive breast massage, heat application, and overfeeding/excessive pumping - these practices increase tissue trauma and milk overproduction, worsening mastitis 2

When to Initiate Antibiotic Therapy

Start antibiotics if symptoms do not improve after 24-48 hours of conservative management, or if the patient presents with severe symptoms initially. 2

First-Line Antibiotic Regimens

Dicloxacillin or cloxacillin (flucloxacillin) - these are the preferred agents because they target Staphylococcus aureus, the most common bacterial cause 1, 4

• Transfer to breast milk is minimal 1, 4
• Typical duration: 10-14 days 3

Alternative for Penicillin Allergy

Cephalexin 500 mg orally every 6 hours - for patients with non-severe penicillin allergy 1

Important Caveat on MRSA

As methicillin-resistant S. aureus becomes more prevalent, consider broader coverage if the patient fails initial therapy or has risk factors for MRSA. 3 Obtain milk cultures to guide antibiotic selection when bacterial infection is suspected. 4, 2

Breastfeeding During Treatment

Breastfeeding from the affected breast is safe and should continue during antibiotic treatment unless the infant's mouth would contact purulent drainage from an abscess. 1 Regular feeding serves as an adjunct to antibiotic therapy by promoting milk removal. 1

Monitoring for Complications

Approximately 10% of mastitis cases progress to breast abscesses requiring drainage. 1 Perform ultrasonography if: 2

• Symptoms worsen despite appropriate treatment
• Recurrent symptoms develop
• Patient is immunocompromised
• A fluctuant mass is palpable

Abscess drainage (surgical or needle aspiration) is required when conservative and antibiotic therapy fail. 1, 3 Breastfeeding can usually continue even with a treated abscess. 3

Hospital Admission Criteria

Admit for intravenous antibiotics if: 2

• Symptoms worsen despite oral antibiotics
• Concern for sepsis (high fever, tachycardia, hypotension)
• Unable to tolerate oral medications
• Immunocompromised status

Prevention Strategies

Optimize breastfeeding technique with proper infant latch - this is the most effective prevention strategy. 2 Poor positioning and restricted feeding precipitate mastitis. 3

• Encourage physiologic breastfeeding rather than pumping when possible 2
• Avoid overstimulation of milk production 2
• Address sore nipples promptly, as they can precipitate mastitis 3

Evidence Quality Note

The evidence base for antibiotic therapy in mastitis is limited - a Cochrane review found insufficient high-quality data to definitively confirm antibiotic effectiveness, though clinical practice strongly supports their use in bacterial cases. 5 The conservative approach of initial symptom management before antibiotics is increasingly supported by recent evidence showing most cases are inflammatory. 2