Mastitis, Emergency Medicine

Basics

Description

Infection of the breast causing pain, swelling, and erythema
Most commonly in women who are breast-feeding
Often with systemic symptoms also:
- Malaise
- Fever
Incidence may be as high as 33% in lactating woman
Onset typically 2 " 3 wk to months postpartum
75 " 95% occur before infant is 3 mo old
- Rare during 1st postpartum week
More common in advanced maternal age and patients with diabetes
Complications:
- Recurrence
- Abscess
- Sepsis
- Necrotizing fasciitis
- Fistula
- Scarring
- Breast hypoplasia

Can occur in full-term infants <2 mo of age

Etiology

Staphylococcus aureus most common
Less common causes:
- Coagulase-negative Staphylococcus
- Streptococcus spp.
- Escherichia coli
- Haemophilus influenzae
- Candida albicans
Risk factors:
- Cleft lip or palate
- Cracked nipples
- Infant attachment issues
- Local milk stasis
- Nipple piercing
- Poor maternal nutrition
- Previous mastitis
- Primiparity
- Restriction from a tight bra
- Sore nipples
- Short frenulum in infant
- Use of a manual breast pump
- Yeast infection

Diagnosis

Signs and Symptoms

Fever and chills
- Temperature usually >38.3 °C (101 °F)
General malaise
Tachycardia
Breast pain, induration, erythema, warmth; usually unilateral
Onset typically 2 " 3 wk to months postpartum while breast-feeding
Rare during 1st postpartum week

History

Flu-like symptoms
Fever, malaise, and myalgia
Breast redness, swelling
Breast pain
Decreased milk outflow

Physical Exam

Breast is:
- Warm
- Tender
- Indurated
- Erythematous " often in a wedge-shaped pattern
Usually unilateral breast involvement
Purulent nipple discharge can occur
Axillary lymph nodes may be enlarged

Essential Workup

Physical exam with special attention to detecting abscess:

Abscess is frequently difficult to detect, but is more common in periareolar area
Purulent nipple discharge with palpation

In neonates:
- Consider the presence of abscess formation and systemic symptoms of infection (e.g., lethargy, poor feeding, fever)
- Sepsis workup may be needed if neonates are febrile and ill appearing
- A complete blood count (CBC) with differential and blood culture need to be considered before the initiation of antibiotics

Diagnosis Tests & Interpretation

Lab
Breast milk culture is usually not required
Imaging

Consider breast US if abscess is suspected
Mammography is not indicated acutely

Differential Diagnosis

Breast engorgement:
- Transient fever <39 °C of 4 " 16 hr duration
- Appearing 48 " 72 hr postpartum
- Bilateral nonerythematous engorgement
Carcinoma (inflammatory)
Cyst, tumor
Abscess formation

Treatment

Pre-Hospital

Generally no pre-hospital treatment needed

Initial Stabilization/Therapy

No specific stabilization

Ed Treatment/Procedures

Continue breast-feeding:
- Child and mother are colonized with the same organisms
- Milk from a breast with mastitis may be protective
- If an infant does not like the taste of milk from a breast with mastitis, then encourage the mother to pump and discard
Massage
Hot/cold therapy
Improve breast-feeding technique:
- May need a lactation consultant
Maintain good maternal hydration.
If mild symptoms and early in disease, antibiotics may not be necessary.
Oral antibiotics for 7 " 14 days:
- ²-Lactamase " resistant penicillin (e.g., dicloxacillin)
- 1st-generation cephalosporin (e.g., cefalexin)
- Clindamycin or trimethoprim/sulfamethoxazole (TMP/SMX) or erythromycin if penicillin allergic
Surgical consultation if evidence of abscess
If considering methicillin-resistant S. aureus (MRSA), treat according to local susceptibility patterns:
- Clindamycin
- TMP/SMX
- Vancomycin

Vertical transmission of HIV (mother to infant) may be increased in mothers with mastitis.

Medication

Amoxicillin/clavulanate: 875 mg PO q12h
Cephalexin: 500 mg PO q6h for 10 days
Clindamycin: 300 mg PO q6h for 10 days
Dicloxacillin: 500 mg PO q6h for 10 days (1st-line treatment)
Erythromycin: 500 mg PO q6h for 10 days
Mupirocin 2% ointment TID
TMP/SMX: 160/800 mg PO q12h:
- Avoid in compromised infants and healthy infants <2 mo old
If MRSA positive: Vancomycin 1 g IV q12h

First Line
Dicloxacillin
Second Line

Amoxicillin/clavulanate
Cephalexin
Erythromycin
TMP/SMX

Follow-Up

Disposition

Admission Criteria

Incision and drainage under general anesthesia may be necessary and require admission
Immunocompromised or evidence of septicemia
Patients with diabetes may account for 1/3 of mastitis cases
Neonatal mastitis generally requires admission

Discharge Criteria

Most patients may be managed in outpatient setting
Most symptoms resolve within 48 hr of therapy
In simple mastitis, breast-feeding may be continued, including using affected breast:
- Gently massage to enhance drainage
- Counsel that this will not harm baby
Breast support, warm compresses, and analgesia for comfort
In frank abscess, discontinue breast-feeding until purulent discharge resolves
Follow-up should be arranged to exclude diagnosis of inflammatory carcinoma

Follow-Up Recommendations

Patients should follow up with primary care physician
Lactation consultant may be helpful

Pearls and Pitfalls

Most cases respond to lactation and warm compresses without antibiotics
Cessation of breast-feeding will lead to increased milk stasis and increased risk for abscess formation
One of the most common complications of mastitis is cessation of breast-feeding

Additional Reading

Dixon JM, Khan LR. Treatment of breast infection. BMJ. 2011;342:d396.
Jahanfar S, Ng CJ, Teng CL. Antibiotics for mastitis in breastfeeding women. Cochrane Database Syst Rev. 2009;(1):CD005458.
Schoenfeld EM, McKay MP. Mastitis and methicillin-resistant Staphylococcus aureus (MRSA): The calm before the storm? J Emerg Med. 2010;(38):e31 " e34.
Spencer JP. Management of mastitis in breastfeeding women. Am Fam Physician. 2008;78:727 " 731.
Stafford I, Hernandez J, Laibl V, et al. Community acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization. Obstet Gynecol. 2008;112:533 " 537.

Codes

ICD9

611.0 Inflammatory disease of breast
675.24 Nonpurulent mastitis associated with childbirth, postpartum condition or complication
778.7 Breast engorgement in newborn
675.14 Abscess of breast associated with childbirth, postpartum condition or complication

ICD10

N61 Inflammatory disorders of breast
O91.23 Nonpurulent mastitis associated with lactation
P83.4 Breast engorgement of newborn
O91.13 Abscess of breast associated with lactation
O91.12 Abscess of breast associated with the puerperium
O91.22 Nonpurulent mastitis associated with the puerperium

SNOMED

45198002 Mastitis (disorder)
78697003 Nonpurulent mastitis associated with childbirth
237441000 Neonatal mastitis (disorder)
63662002 purulent mastitis associated with childbirth (disorder)

Home

Erectile Dysfunction

Doctor123.org