What is the treatment for mastitis in a breastfeeding patient?

Treatment of Mastitis in Breastfeeding Patients

For breastfeeding women with mastitis, start with 1-2 days of conservative management (NSAIDs, ice, continued breastfeeding), and if symptoms do not improve within 12-24 hours, initiate antibiotic therapy with cephalexin 500 mg orally four times daily or dicloxacillin 500 mg orally four times daily, while continuing to breastfeed from the affected breast. 1, 2

Initial Conservative Management (First 12-24 Hours)

• Begin with frequent breast emptying through direct breastfeeding rather than pumping, as 14-20% of cases resolve spontaneously within this timeframe 1, 2
• Administer NSAIDs for pain control and anti-inflammatory effect 2
• Apply ice to reduce inflammation 2
• Critical pitfall to avoid: Do not use heat application, aggressive breast massage, or excessive pumping, as these worsen inflammation and tissue trauma 1, 2

When to Initiate Antibiotics

• Add antibiotics if symptoms do not improve within 12-24 hours of conservative management, as delaying treatment increases the risk of abscess formation (occurs in approximately 10% of mastitis cases) 1, 3
• Immediate antibiotic therapy is warranted if the patient presents with fever and chills, indicating systemic involvement 4

First-Line Antibiotic Selection

Preferred first-line agents (both equally effective):

• Cephalexin 500 mg orally four times daily - safe during breastfeeding with minimal transfer to breast milk 1, 5
• Dicloxacillin 500 mg orally four times daily - targets methicillin-susceptible Staphylococcus aureus, which causes the majority of infectious mastitis cases 1, 5, 6

Alternative antibiotics for penicillin-allergic patients:

• Erythromycin or azithromycin are acceptable alternatives, though there is a very low risk of infantile hypertrophic pyloric stenosis if used during the first 13 days of the infant's life 1
• Amoxicillin/clavulanic acid is a broad-spectrum option safe during breastfeeding 1

For suspected or confirmed MRSA (consider if high local prevalence, previous MRSA infection, or no response to first-line therapy):

• Clindamycin, though use with caution as it may increase GI side effects in the infant 1

Continued Breastfeeding During Treatment

• Continue breastfeeding from the affected breast throughout antibiotic treatment - this does not pose a risk to the infant and helps resolve the mastitis 1, 4, 3
• Regular breast emptying through continued breastfeeding is essential for treatment success 4, 7
• Even if a breast abscess develops, breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage 4
• Never discontinue breastfeeding, as this worsens mastitis and increases abscess risk 5

Monitoring and Follow-Up

• Reassess within 48-72 hours if symptoms worsen or do not improve 1
• Consider obtaining milk cultures to guide antibiotic therapy, particularly if symptoms are not responding to first-line treatment 1, 2
• Perform ultrasound to rule out abscess formation if symptoms persist despite appropriate antibiotic therapy 2

Management of Complications

• Breast abscess occurs in approximately 10% of mastitis cases and requires drainage via ultrasound-guided needle aspiration or surgical drainage 1, 4, 3
• Hospitalization is indicated for fever and chills persisting despite outpatient antibiotics, concern for sepsis, or need for IV antibiotics 4, 5
• During hospitalization, provide access to breast pump if prolonged separation occurs and ensure availability of trained lactation support staff 4