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Mastitis, Emergency Medicine

Basics

Description

- 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

- Fever and chills - Temperature usually >38.3 °C (101 °F)

- Breast is: - Warm - Tender - Indurated - Erythematous " often in a wedge-shaped pattern

- Breast engorgement: - Transient fever <39 °C of 4 " 16 hr duration - Appearing 48 " 72 hr postpartum - Bilateral nonerythematous engorgement

- 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

  • Infection of the breast causing pain, swelling, and erythema
  • Most commonly in women who are breast-feeding
  • Often with systemic symptoms also:
  • 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 oldRare during 1st postpartum week
  • More common in advanced maternal age and patients with diabetes
  • Complications:RecurrenceAbscessSepsisNecrotizing fasciitisFistulaScarringBreast hypoplasia

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

Etiology

  • Staphylococcus aureus most common
  • Less common causes:Coagulase-negative StaphylococcusStreptococcus spp.Escherichia coliHaemophilus influenzaeCandida albicans
  • Risk factors:Cleft lip or palateCracked nipplesInfant attachment issuesLocal milk stasisNipple piercingPoor maternal nutritionPrevious mastitisPrimiparityRestriction from a tight braSore nipplesShort frenulum in infantUse of a manual breast pumpYeast infection

Diagnosis

Signs and Symptoms

  • Fever and chillsTemperature 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:WarmTenderInduratedErythematous " 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 appearingA 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 durationAppearing 48 " 72 hr postpartumBilateral 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 organismsMilk from a breast with mastitis may be protectiveIf 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:ClindamycinTMP/SMXVancomycin

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 drainageCounsel 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Abscess
  • Cellulitis
  • Community-acquired MRSA

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)