When are pharmacological interventions necessary for mastitis and what are the alternative treatments?

When Pharmacological Interventions Are Necessary for Mastitis

Antibiotics should be initiated if conservative management (NSAIDs, ice, continued breastfeeding) fails to improve symptoms within 12-24 hours, or immediately if the patient presents with systemic signs of infection such as fever >38.5°C, severe malaise, or concern for sepsis. 1

Initial Management: Conservative Measures First

• Most mastitis cases are inflammatory rather than infectious, requiring only supportive care for 1-2 days before considering antibiotics 1
• Conservative measures include:
  • NSAIDs for pain and inflammation 1
  • Ice application to affected breast 1
  • Continued direct breastfeeding from the affected breast (feeding is more effective than pumping and helps resolve inflammation) 2, 1
  • Minimizing pumping, which can worsen inflammation through overstimulation 1

When to Start Antibiotics

Initiate antibiotic therapy if:

• No improvement after 12-24 hours of conservative management 1
• Presence of fever and systemic symptoms at presentation 2, 3
• Worsening symptoms despite conservative measures 1
• Immunocompromised patients (consider earlier initiation) 1

Antibiotic Selection

First-line antibiotics target Staphylococcus aureus and common skin flora:

Preferred Oral Agents

• Dicloxacillin (penicillinase-resistant penicillin) 4, 3
• Cephalexin (first-generation cephalosporin) 3
• These agents are effective against Staphylococcus and Streptococcus species 1

Important Considerations

• Obtain milk cultures before starting antibiotics to guide therapy, especially if symptoms worsen or recur 1
• Consider coverage for methicillin-resistant S. aureus (MRSA) if it is prevalent in your community or if initial therapy fails 3
• Narrow-spectrum antibiotics are preferred to minimize disruption of normal flora 1

When Hospitalization and IV Antibiotics Are Required

Admit for inpatient management with IV antibiotics if:

• Concern for sepsis or systemic toxicity 2, 1
• Failure of outpatient oral antibiotic therapy 1
• Suspected or confirmed breast abscess requiring drainage 2, 3
• Severe illness with inability to tolerate oral medications 1

Inpatient Management Principles

• Continue breastfeeding or milk expression even during hospitalization 2
• Provide appropriate pain management, as pain can exacerbate symptoms 2
• Ensure access to breast pump if prolonged separation from infant occurs 2

Management of Complications

Breast Abscess (occurs in ~10% of mastitis cases)

• Requires drainage via needle aspiration or surgical intervention 2, 3
• Breastfeeding can continue on affected side as long as infant's mouth does not contact purulent drainage 2, 3
• Obtain ultrasound to identify abscess in patients with worsening or recurrent symptoms 1

Alternative and Adjunctive Pharmacological Treatments

Probiotics

• Not recommended - insufficient evidence supports their use for treatment or prevention of mastitis 1

Antifungal Therapy

• Consider only if candida infection develops as complication of antibiotic therapy 5
• Not a primary treatment for bacterial mastitis 5

Critical Pitfalls to Avoid

• Do NOT discontinue breastfeeding - this worsens mastitis and increases abscess risk 2, 3
• Avoid excessive pumping, heat application, and aggressive breast massage - these worsen inflammation through overstimulation 1
• Do not delay antibiotic treatment in patients with systemic symptoms - this increases abscess formation risk 2
• Do not rely on oral antibiotics in severely ill patients with nausea, vomiting, or signs of sepsis 4