Approach
The goal of treatment for mastitis is to provide prompt and appropriate management to prevent complications such as a breast abscess. Patients with a breast abscess are best managed by an interdisciplinary team that includes surgeons and radiologists.[30]
For lactational mastitis, current evidence seems to favor proactive breast emptying and, in the presence of severe or prolonged symptoms or systemic signs, the use of antibiotics.[1][40] However, one review concluded that randomized controlled trials provide little evidence to evaluate the effect of antibiotic therapy on lactating mastitis.[42] The trials included in the review were methodologically poor with small sample size.[42]
Lactational mastitis
Treatment includes:[1][40][43]
Effective milk removal
Antibiotic therapy
Warm compresses
Symptomatic relief
Supportive counseling.
When signs and symptoms of mastitis are not severe, or have not been present more than 12-24 hours, it may be possible to manage the condition without antibiotics.[42][44]
Effective milk removal may involve continued frequent nursing (e.g., breast-feeding 8-12 times per day), breast pumping on the affected side if indicated, and/or massage if tolerated. Supportive measures should include:
Analgesia for pain relief if necessary (e.g., acetaminophen, ibuprofen)
Increased fluid intake
Warm and/or cold compresses
Counseling, including reassurance about the value of breast-feeding, and safety of continued breast-feeding (that the milk from the affected breast will not harm the infant, where appropriate). Guidance on treatment, how to continue breast-feeding or expressing milk, and follow-up and continued support, is required.[1] These measures may require a lactation consultant.
Bromocriptine should not be used to suppress lactation in women with lactational mastitis.[45] Rare cases of hypertension, myocardial infarction, stroke, and mental disorders have been reported.
Antimicrobial therapy
Antibiotics are indicated for patients with:[1]
Acute pain
Severe symptoms or lasting more than 12-24 hours
Fever
Systemic infection
Positive microbiology studies.
As Staphylococcus aureus is the most common pathogen, antibiotics with activity against staphylococci should be used. The decision to start oral or intravenous antimicrobials at the time of initial presentation depends on clinical judgment and the severity of illness. If MRSA can be excluded by culture, or if MRSA is not prevalent locally, 10-14 days of oral dicloxacillin is the initial choice.[40] Cephalexin, a first-generation cephalosporin, may also be considered, but it has a broad spectrum of coverage and is more likely to promote the development of MRSA.[46] Cephalexin may be prescribed for patients with a penicillin allergy (although it should be used with caution as a minority of patients may experience cross-reactivity between penicillins and cephalosporins); clindamycin is appropriate for patients with severe penicillin hypersensitivity.[40]
Suspected MRSA infection
Isolates that are resistant to methicillin have been reported in many regions; local resistance patterns need to be considered. Lactational mastitis due to community-acquired MRSA (CA-MRSA) infection is frequently reported in women who are otherwise healthy and lack traditional risk factors for hospital-acquired MRSA.[47][48] Clindamycin or trimethoprim/sulfamethoxazole may be appropriate treatment options for CA-MRSA.[49] Trimethoprim/sulfamethoxazole should not be given if the mother is breast-feeding a jaundiced infant (because of the risk of kernicterus), a premature infant, or a baby aged less than 30 days.[40][50] Doxycycline can also be used for CA-MRSA infections. It was previously thought that the mother must not breast-feed and would need to pump milk to maintain supply during the antibiotic course. However, short-term use of doxycycline may be considered acceptable during lactation in courses up to 21 days, if no alternative is available.[51][52]
Trimethoprim/sulfamethoxazole is an acceptable choice if hospital-acquired MRSA is suspected. An alternative antibiotic is required if the mother is breast-feeding a jaundiced infant (because of the risk of kernicterus), a premature infant, or a baby aged less than 30 days.[40][50]
Patients may require hospital admission for parenteral antibiotic therapy, pain management, and/or surgical intervention, particularly if they:
Are immunosuppressed
Appear toxic (e.g., bacteremia/sepsis is suspected)
Are hemodynamically unstable
Exhibit a rapidly progressive infection
Do not respond to outpatient antibiotic therapy.
Response to antimicrobial therapy
Infections should begin to respond to antibiotics within 48 hours. If there is no improvement within this time frame, breastmilk culture and assay of antibiotic sensitivities should be ordered, and the possibility of alternative diagnoses considered. Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities.
If the infection is worsening despite oral therapy or if the infection is severe and occurs in a hospitalized patient, intravenous vancomycin can be used. This antibiotic covers both CA-MRSA and hospital-acquired MRSA. Other antibiotics with activity against MRSA can be used in refractory cases, but experience with these agents in treating mastitis is limited. Information is lacking regarding levels in breast milk.
Candidiasis
When nipple candidiasis is diagnosed, both mother and infant must be treated simultaneously. A topical antifungal should be used in the mother, combined with topical application of an antifungal suspension in the infant’s mouth. Treatment should continue for 48 hours after resolution of symptoms.[43]
Isolated nipple infection
An isolated nipple infection can be treated with topical antimicrobial therapy.
Nonlactational mastitis
Differentiating between infectious and noninfectious nonlactational mastitis is difficult. Therefore, antimicrobial therapy, without any observation period, is the initial treatment for all patients presenting with nonlactational mastitis.
Suspected infectious nonlactational mastitis
Antimicrobial therapy, without any observation period, is the initial treatment.
Supportive measures should include analgesia, if necessary.
Persistent infection despite the appropriate use of antibiotics and drainage procedures should prompt further investigation with fungal cultures. Choice of antifungal therapy depends on the result of the culture.
For postoperative wound infections, a surgeon should be consulted.
Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body.
Tuberculosis (TB) of the breast is rare and requires anti-TB therapy under specialist guidance. A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention.[6] See Extrapulmonary tuberculosis (Management).
Suspected noninfectious nonlactational mastitis
Antimicrobial therapy, without any observation period, is the initial treatment. Noninfectious nonlactational mastitis is a diagnosis of exclusion.
Supportive measures should include analgesia, if necessary.
For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice. However, there is evidence to suggest that surgical management, with or without corticosteroids, results in high complete remission rates.[53]
Isolated nipple infection
An isolated nipple infection can be treated with topical antimicrobial therapy.
Refractory mastitis
In refractory mastitis, the following diagnoses should be considered:
Multiple and/or deep abscess
Coexistent malignancy
Underlying breast abnormality
Fistula
Fungal infection
Granulomatous mastitis
TB
Atypical mycobacteria
Other unusual infectious pathogen or multidrug resistance.
An ultrasound should be performed looking for possible underlying abscess. A biopsy should be considered. Cultures should be performed to exclude atypical microorganisms and/or a multidrug-resistant pathogen. If a fistula is detected it needs to be excised (fistulectomy) along with its feeding duct.[54]
Breast abscess
Needle aspiration (18- to 19-gauge needle) with local anesthesia, with or without ultrasound guidance can be used to drain an abscess.[5][30][55] For complete drainage of the abscess, multiple aspirations may be necessary (daily aspiration for 5-7 days). Aspirated fluid can be sent for culture to guide subsequent antibiotic therapy.
The risk of failure for needle aspiration is greater with abscesses >5 cm in diameter.[5][55] If complete clearance of frank pus is problematic with fine needle aspiration, management options include the use of a larger needle, surgical drainage, or repeat percutaneous catheter drainage (drainage without placing an indwelling catheter). Incision and drainage is reserved for patients in whom aspiration fails after several attempts (guidance suggests at least 3-5 attempts) and/or for multiloculated or large abscesses.[30][55][56] Repeat percutaneous drainage may also be considered for large collections. Repeat drainage appears to be as effective as indwelling catheter drainage, but with reduced risks and increased patient comfort.[30]
Some evidence exists for the application of a negative suction drain through a mini periareolar incision. One retrospective study of women with lactational breast abscess reported that negative suction pressure was associated with shorter hospital stay and a higher rate of continuation of breast-feeding than incision and drainage.[57]
Antibiotic therapy
Antimicrobial therapy is prescribed in addition to drainage of the abscess. Without drainage of the abscess, antimicrobial therapy is unlikely to be successful because the wall of the abscess protects bacteria from the action of the antibiotics.[1]
If MRSA can be excluded, or if MRSA is not prevalent locally, a breast abscess can be treated with an oral or intravenous antibiotic that is active against methicillin-sensitive staphylococci. However, studies have found that community-acquired MRSA (CA-MRSA) is a significant pathogen among women admitted to hospital with puerperal breast abscess.[10][58] In cases of suspected or confirmed CA-MRSA, or in a patient with a penicillin allergy, trimethoprim/sulfamethoxazole, or doxycycline, or clindamycin can be used. Trimethoprim/sulfamethoxazole should not be given if the mother is breast-feeding a jaundiced infant (because of the risk of kernicterus), a premature infant, or a baby aged less than 30 days.[40][50] It was previously thought that mothers prescribed doxycycline must not breast-feed and would need to pump milk to maintain supply during the antibiotic course. However, short-term use of doxycycline may be considered acceptable during lactation in courses up to 21 days if no alternative is available.[51][52]
Intravenous vancomycin may be used in more severe cases and in hospitalized patients where hospital-acquired MRSA is suspected. It is important to refer to local antibiotic prescribing policies and, where possible, be guided by sensitivities on culture.
Chronically infected tissue
After the acute phase has subsided, chronically infected tissue and the major lactiferous duct associated with the abscess leading to the nipple may need to be excised.[30] If the incision does not interfere with breast-feeding, a lactating mother can continue to nurse. If the incision does interfere with nursing, milk can be regularly removed with a breast pump.
Recurrence of mastitis and/or breast abscess
May occur with delayed therapy, a short course of therapy, inappropriate therapy, and in Staphylococcus carriers. Recurrent mastitis or persistence of a mass after therapy may be due to a breast abscess or underlying breast lesion. Granulomatous mastitis has a high recurrence rate. Smoking cessation should also be encouraged, to minimize the risk of recurrence.
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