Contributor: Bruce Drukker, MD
Last Update: 3/1/2010
Women presenting with painful breasts and breast erythema with or without a dominant, tender, palpable mass require prompt, careful intervention with follow-up about 48 – 72 hours after instituting therapy.
Mastitis is most commonly associated with lactation but is also seen in the nonpuerperal woman. Mastitis has been reported in 1-3% of lactating women although up to 9.5% of lactating women reported symptoms of mastitis in telephone interviews. The condition is most likely due to introduction of bacteria into the breast ductal system through nipple cracks concomitant with breastfeeding.
Mastitis also occurs in nonpuerperal women. This may also be associated with nipple trauma and introduction of bacteria. Rarely it may be associated with tuberculosis, syphilis, actinomycosis or injection of narcotic substances into superficial veins of the breast.
Presentation: Patients present with malaise, fever, localized mastalgia and erythema. Occasionally a palpable mass is noted. Infrequently, the patient will report spontaneous nipple or periareolar drainage of purulent material.
Plugged milk ducts in lactating patients
Inflammatory breast carcinoma
Superficial thrombophlebitis of the breast
Recurrent subareolar abscess
The differentiation between mastitis and inflammatory carcinoma of the breast can be difficult. In both mastitis and inflammatory carcinoma, the primary lesion may be obscured by edema. In general, the diagnosis of inflammatory carcinoma is clinical including biopsy with only the exceptional mammogram showing a gross lesion.
History and physical assessment
Culture of any purulent material
Consider ultrasound to determine solid from cystic or septate, complex lesions.
Mammography may be used in exceptional situations but is painful for patients with mastitis.
Staphylococcus aureus – consider MRSA
Granulomatous findings – extremely rare: mycobacterium tuberculosis, syphilis and actinomycosis
Prompt: CBC, Culture purulent material both aerobic and anaerobic specimens.
Start Treatment. Think MRSA possibility.
Re-evaluate in 48-72 hours.
Outpatient oral antibiotics:
Non-severe infection without risk for MRSA
Dicloxacillin 500 mg qid x 10-14 days
Cephalexin 500 mg qid x10-14 days
If hypersensitivity to beta lactam, clindamycin 300mg po qid X 10-14 days
Non-severe infection with risk for MRSA:
Trimethoprim – sulfamethoxazole 1-2 tabs po bid X 10-14 days
Clindamycin 300 mg po qid X 10-14 days
If severe infection, hospitalize patient for intravenous antibiotics
Nafcillin / oxacillin 2 g IV q 4 hours if MRSA not suspected
Vancomycin 1 g 1V q 12 hours if MRSA suspected
Symptomatic relief with anti-inflammatory agents and cold compresses may reduce local pain and swelling.
Breastfeeding should continue during treatment. Pumping may be necessary. Warning: Mastitis that is recurrent generally indicates inadequate antibiotic therapy; however, occasionally it heralds breast cancer.
This condition presents with symptoms and clinical findings of mastitis plus a fluctuant mass.
The primary management of breast abscess is drainage, along with antibiotic therapy appropriate for underlying cause of abscess. Proceed with H&P, CBC and culture of drainage as above. Consult surgery to evaluate for I & D vs. needle aspiration.
Following I & D, patients require careful weekly follow up until the infection site has completely healed. See antibiotics above.