ID
Mastitis
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Mastitis
, Lactation Mastitis, Breast Abscess, Breast Abscess During Lactation
See Also
Breast Feeding Problems for the Mother
Epidemiology
Incidence
: 9-33% of lactating women
Most common in first few weeks and nearly all cases within first 3 months
Pathophysiology
Gene
rally occurs in
Lactation
several weeks postpartum
Bacteria
enter through a cracked nipple
Causes
Staphylococcus aureus
Escherichia coli
Haemophilus
Influenza
e
Symptoms
Fatigue
Malaise
Myalgias
Headache
Signs
Fever
Unilateral
Breast
inflammation
Warmth
Tenderness
Erythema
Observe for signs of Breast Abscess
Requires needle aspiration
Labs
Milk Culture
Indications (not routine)
Severe Mastitis
Refractory despite optimal antibiotics for at least 48 hours
Hospital acquired infection
Technique
Cleanse nipple
Hand express small quantity of
Breast Milk
and discard
Hand express a sample into a sterile container
Differential Diagnosis
Inflammatory
Breast Cancer
Management
Gene
ral Measures
Tylenol
or
Ibuprofen
Ensure adequate hydration
Apply warm packs and local massage
Alternate feeding positions
Antifungal
s (Monilial Infection)
Topical Antifungal
s on
Breast
Oral
Nystatin
for infant
Continue with frequent
Breast
feeding (except if Breast Abscess present)
Risk of Breast Abscess if
Breast
engorgement occurs
Ensure proper technique (see prevention below)
Safe for infant to continue to feed despite infection with following exceptions
Mother HIV positive
Breast Abscess
Discard
Breast Milk
for the first 24 hours on antibiotics
Resume
Breast Feeding
after the first 24 hours on antibiotics
Management
Antibiotics
Course: 10 to 14 days
Coverage:
Staphylococcus aureus
(or as directed by culture)
May observe localized
Breast
redness, tenderness without systemic symptoms or abscess for 24 hours
For first 24 hours may use general measures above and hold antibiotics
Start antibiotics by 24 hours if not improving, systemic symptoms, other risks
Antibiotics: Nursing Mothers
Amoxacillin-Clavulanate (
Augmentin
) 875 mg orally twice daily
Cephalexin
(
Keflex
) 500 mg orally four times daily
Dicloxacillin
500 mg orally four times daily
Clindamycin
300 mg orally four times daily (for
MRSA
)
Antibiotics: Non-
Breast Feeding
women
Trimethoprim-sulfamethoxazole (
Septra
) 160mg/800 mg orally twice daily (for
MRSA
)
May be used in
Lactation
after first 2 months of life
Management
Breast Abscess
Obtain
Bacteria
l culture
Needle aspiration under
Ultrasound
guidance (preferred, 60% effective)
Attempt to irrigate the abscess via the same needle used for aspiration
May repeat up to 3 times if fails to resolve (then incise in drain if still refractory)
Incision and Drainage
Indicated in refractory cases (after 3 attempted needle aspirations)
Also first-line measure in very superficial lesions, with skin thinning over the abscess
References
Sacchetti in Herbert (2016) EM:Rap 16(5): 1
Follow-up
Early antibiotics prevent abscess formation
If not better in 48 hours examine
Breast
for abscess
Consider
Incision and Drainage
Prevention
Optimal
Breast Feeding Technique
with good latch-on by infant
Address predisposing factors early
Sore nipples suggest problems
Correct latch-on problems
Address dry nipples with lanolin
Avoid plastic-backed
Breast
pads
Evaluate infant for anatomic problems (e.g. short frenulum,
Cleft Palate
)
Cracked nipples colonized with
Staphylococcus aureus
should be treated
Oral antibiotics (e.g.
Dicloxacillin
) are preferred
Livingstone (1999) J Hum Lact 15:241-6 [PubMed]
Blocked milk ducts should be unblocked
Blocked ducts will appear with a bleb overlying a tender, red area adjacent to nipple
Remove bleb with moist cloth
Yeast infection should be treated (both infant and mother)
Infant: See
Thrush
for management options
Mother
Topical agents:
Nystatin
or
Ketoconazole
Oral agents:
Fluconazole
400 mg on day #1, then 200 mg orally daily for 10 days
Chetwynd (2002) J Hum Lact 18:168-71 [PubMed]
References
Barbosa-Cesnik (2003) JAMA 289:1609-12 [PubMed]
Spencer (2008) Am Fam Physician 78(6): 727-32 [PubMed]
Westerfield (2018) Am Fam Physician 98(6): 368-73 [PubMed]
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