What is the recommended management, including antibiotic therapy, for a 35‑year‑old postpartum woman, status post cesarean delivery, currently breastfeeding, diagnosed with Category III cat‑scratch disease (Bartonella henselae infection)?

Management of Category III Cat-Scratch Disease in a Breastfeeding Postpartum Woman

For this 35-year-old breastfeeding woman with Category III (disseminated/extranodal) cat-scratch disease, erythromycin 500 mg four times daily is the recommended treatment, as it is the only safe antibiotic option during breastfeeding and pregnancy, while tetracyclines like doxycycline are absolutely contraindicated. 1, 2

Immediate Management

Start erythromycin 500 mg orally four times daily immediately for treatment of disseminated cat-scratch disease in this breastfeeding patient. 1, 2 This is the only macrolide specifically recommended for pregnant and breastfeeding women in the guidelines, as tetracyclines (doxycycline) must be completely avoided. 1, 2

Why Not Other Antibiotics?

• Doxycycline is absolutely contraindicated during breastfeeding and pregnancy due to fetal/infant harm. 1, 2
• Azithromycin, while first-line for non-pregnant/non-breastfeeding patients, is not specifically endorsed in the guidelines for breastfeeding women—only erythromycin receives explicit approval for this population. 2
• Fluoroquinolones should not be used during pregnancy or breastfeeding. 1

Treatment Duration and Monitoring

• Continue erythromycin for at least 7-10 days for cutaneous/lymph node involvement. 1
• For Category III disease with extranodal involvement (hepatosplenic, bone, CNS), extend treatment to several weeks and consider adding rifampin if response is inadequate, though this requires careful risk-benefit assessment in breastfeeding. 2, 3
• Monitor for treatment failure within the first week—persistent fever or worsening symptoms should prompt re-evaluation for complications like endocarditis or CNS involvement. 2, 4

Critical Assessment for Disseminated Disease

Since this is Category III disease, you must evaluate for specific organ involvement:

• Hepatosplenic involvement: Check liver enzymes and consider abdominal imaging if right upper quadrant pain, hepatomegaly, or persistent fever despite treatment. 2, 3
• CNS involvement: Assess for headache, altered mental status, or focal neurologic deficits—these require urgent evaluation and potentially gentamicin addition (though problematic in breastfeeding). 2
• Endocarditis: Listen for new murmurs, check for stigmata of endocarditis, and obtain echocardiography if persistent fever with bacteremia suspected. 5, 6
• Bone involvement: Evaluate for localized bone pain or osteomyelitis, which may require prolonged therapy. 2, 6

Special Considerations for Postpartum Status

• The recent cesarean delivery does not change antibiotic choice, but monitor the surgical site for any signs of wound infection, which could complicate the clinical picture. 1
• Breastfeeding can continue while on erythromycin, as it is considered safe. 1, 2
• Wound care: Ensure any cat scratch sites are cleaned thoroughly with soap and water to prevent secondary bacterial infection. 2

When to Escalate or Add Therapy

• If fever persists beyond 48-72 hours on erythromycin alone, consider adding rifampin 300 mg twice daily, though data in breastfeeding are limited. 3
• For severe hepatosplenic disease, some evidence supports gentamicin (73% efficacy with rapid response within 48 hours), but this requires careful consideration given breastfeeding status and potential infant toxicity. 2
• If endocarditis is confirmed, the regimen becomes doxycycline plus gentamicin for 6 weeks, which would necessitate temporary cessation of breastfeeding. 5

Prevention of Recurrence

• Long-term suppression with erythromycin should be considered if relapse occurs after completing initial therapy. 1, 2
• Counsel on cat exposure: Avoid rough play with cats, do not allow cats to lick open wounds, promptly wash any future scratches, and implement flea control for household cats. 2, 4

Common Pitfalls to Avoid

• Do not use azithromycin reflexively just because it's first-line in non-pregnant patients—erythromycin is the specifically endorsed macrolide for breastfeeding women. 1, 2
• Do not underestimate Category III disease—this is not self-limited lymphadenopathy and requires aggressive treatment with close monitoring for complications. 2, 6
• Do not delay imaging if hepatosplenic or bone involvement is suspected, as these require confirmation and may need prolonged therapy. 2, 3
• Do not test the cat for Bartonella—this provides no diagnostic or management benefit. 2