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Lactational Mastitis

• Introduction
• Signs and symptoms
• Management
• Breast abscess

Introduction

Mastitis is an inflammation of the breast which may or may not be associated with a bacterial infection. In infective mastitis, Staphylococcus aureus is the most common pathogen. Mastitis occurs in 20% of breastfeeding women in Australia. Most episodes of mastitis occur in the first six weeks postpartum.

Heath authorities recommend that women with mastitis and/or breast abscess continue to breastfeed - it is safe for healthy infants to receive this milk.

Signs and symptoms

Breast 

General fever

Links to Algorithm / Patient information

Management

Early management:

• Maintain breastfeeding
• Effective milk removal (see RWH Mastitis Algorithm &/or fact sheet)
• Analgesia: paracetamol or NSAID (such as ibuprofen)

Subsequent management:

If symptoms are not resolving within 12 to 24 hours, antibiotic treatment may be required (in conjunction with continuing to maintain breastfeeding or effective milk removal by expressing).

Recommended antibiotic regime:

First line: Flucloxacillin (or dicloxacillin)
Dose: 500mg four times a day for 5 days

Penicillinase-resistant penicillins are widely used for bacterial infections caused by Staphylococcus aureus. Both are well absorbed orally and either drug is first choice for mastitis.

For intravenous dosing: Flucloxacillin is preferred, as Dicloxacillin has a tendency to cause phlebitis when administered intravenously.

Side-effects:

• common - nausea, diarrhoea, rash
• rare - anaphylactic shock, cholestatic jaundice (usually in elderly patients on prolonged courses of flucloxacillin).

Monitor hepatic function if treatment continues for > 2 weeks, especially if there are other risk factors.

Considered safe for breastfeeding women. Does not accumulate in breastmilk and levels in breast milk are undetectable 6 hours after dosage.

If allergic to penicillin:
Cephalexin
Dose: 500mg four times a day for 5 days

Moderate spectrum cephalosporin that is active against staphylococci, streptococci and some Gram-negative bacteria (eg E. coli). Cephalexin is absorbed orally.

As infective mastitis is usually caused by Staphlococcus aureus, penicillinase-resistant penicillin is generally preferred over the broader-spectrum cephalexin. Cephalexin is usually prescribed for mastitis in women with a history of hypersensitivity to penicillin. About 3-6% of individuals with penicillin hypersensitivity have a cross-reaction to cephalosporins.

Side-effects:

• common - nausea, diarrhoea, rash
• rare - anaphylactic shock
  

Considered safe for breastfeeding women. Insignificant amounts are excreted into breastmilk

If there is a history of immediate penicillin hypersensitivity:

Clindamycin
Dose: 450mg four times a day for 5 days

Active against Gram-positive aerobes and most anaerobes. Used as a second choice when individuals cannot tolerate usual therapy.

Side-effects:

• common - diarrhoea, nausea, vomiting
• rare - anaphylaxis, blood dyscrasias, jaundice

Use in lactating women with caution, may cause loose bowel actions in baby. One report of  bloody diarrhoea in infant of mother given intravenous clindamycin.

(Note: erythromycin is not recommended, as approximately 20% of Staphylococcus aureus is resistant to erythromycin).

Women who are very unwell and / or have little support at home may need to be admitted for intravenous antibiotics:

Investigations

If hospital admission is required, appropriate investigations may include:

• FBC
• CRP
• Blood cultures if temperature > 38.5C
• Breastmilk culture
• Diagnostic ultrasound

Flucloxacillin
Dose: 2g IV every 6 hours

If allergic to penicillin: Cephazolin
Dose: 1g IV every 8 hours

If there is a history of immediate penicillin hypersensitivity:

Clindamycin
Dose: 450mg IV every 8 hours

Or

Vancomycin (if pathogen sensitivity confirmed)
Dose: 1g IV every 12 hours

In all cases, change to oral antibiotics as soon as possible.

ALWAYS refer to a Lactation Consultant for appropriate feeding assessment and advice. Effective drainage of breastmilk either by breastfeeding and / or expressing is essential to decrease the risk of breast tissue involution and/ or breast abscess formation.

 

 

Breast abscess

An abscess is a collection of pus in the breast, usually occurring following an episode of mastitis. The diagnosis can be confirmed by ultrasound. The abscess requires drainage (either percutaneous aspiration or open drainage).
Women with a breast abscess need to be referred to a Breast Surgeon for management.

Management

For proven breast abscess, needle aspiration or surgical drainage is the standard management.
Treatment of breast abscess requires confirmation of pathogen sensitivity for antibiotic treatment.

References

Academy of Breastfeeding Medicine (2002). "Clinical Protocol Number 4: Mastitis." ABM News and Views 8(4): 30, 34. www.bfmed.org/protocol/proto4.html

Amir LH, Forster D et al. Incidence of breast abscess in lactating women: report from an Australian cohort. BJOG 2004; 111: 1378-81.

Hale TW. Medications and Mothers' Milk. 2004. Pharmasoft Publishing. 11th Edition. Texas USA.

Pharmacy Department, The Royal Women's Hospital. Drugs and Breastfeeding. 2004 Melbourne, Australia

Therapeutic Guidelines: Antibiotic (2003). North Melbourne, Australia, Therapeutic Guidelines Limited.

World Health Organization (2000). Mastitis: Causes and Management. Geneva, WHO/FCH/ CAH/00.13. Mastitis : Causes and management

 

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