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Mastitis
Lisa Rahangdale, MD
RID Seminar
October 26, 2004
Mastitis
An acute inflammation of the
interlobular connective tissue
within the mammary gland
Outline
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Epidemiology
Presentation
Predisposing factors
Microbiology
Treatment
Complications
Effect on breast milk
Epidemiology
• Incidence 2-33%
– ACOG reports 1-2% in U.S.
– Most common worldwide <10%
• Most common 2nd-3rd week postpartum
– 74-95% in first 12 weeks
– Can occur anytime in lactation
WHO 2000
Presentation
• Systemic illness: Chills, myalgias
• Fever of ≥ 38.5
• Tender, hot, swollen wedge-shaped
erythematous area of breast
• Usually one breast
Differential Diagnosis
• Fullness: bilateral, hot, heavy, hard, no
redness
• Engorgement: bilateral, tender, +/- fever,
minimal diffuse erythema
• Blocked Duct: painful lump with overlying
erythema, no fever, feel well, particulate
matter in milk
Differential Diagnosis
• Galactocele: smooth rounded swelling
(cyst)
• Abscess: tender hard breast mass, +/fluctuance, skin erythema, induration, +/fever
• Inflammatory Breast Carcinoma: unilateral,
diffuse and recurrent, erythema, induration
Causes and
Predispsing factors
Causes
• Milk Stasis
– Stagnant milk increases pressure in breast
leading to leakage in surrounding breast
tissue
– Milk, itself, causes an inflammatory response
• +/- Infection
– Milk provides medium for bacterial growth
Causes
• Study of 213 ♀, 339 breasts
• 3 groups
– Milk stasis (bacteria<10^3, leuk<10^6)
– Noninfectious inflammation (bacteria <10^3, leuk
>10^6)
– Infectious (bacteria >10^3, leuk>10^6)
• Randomized treatment
– No intervention
– Systematic emptying of breast
– Infectious group with 3rd intervention: antibiotics
(PCN, Amp, Erythro) and systematic emptying
Thomsen 1984
Treatment
Milk Stasis
N
Sx duration (mean)
No treatment
63
63
2.3 d
2.1 d
24
24
7.9 d
3.2 d
p<.001
Emptying
55
55
6.7 d
4.2 d
p<.001
Abx +Emptying
55
2.1 d
p<.001
Emptying
p value
Noninfectious
No treatment
Emptying
Infectious
No treatment
Thomsen 1984
Causes
• “Poor results”
– Milk stasis (10) – 3 recurrences, 7 impaired
lactation
– Noninfectious (20) – 13 recurrences
– Infectious (76 – only 2 in Abx group) – 6
abscesses, 21 recurrences
• Could not clinically tell difference between
the groups without lab data.
• Conclusion: Treat with antibiotics
Thomsen 1984
Predisposing factors
• Improper nursing technique
– Timing of feeds
– Poor attachment
• Oversupply of milk
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Overabundant milk supply
Lactating for multiples
Rapid weaning
Blocked nipple pore or duct
• Pressure on Breast
– Tight Bra
– Car seatbelt (yes, this is actually listed)
– Prone sleeping position
WHO 2000, Academy of Breastfeeding Medicine 2004
Predisposing factors
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Damaged nipple (nipple fissure)
Primiparity
Previous history of mastitis
Maternal or neonatal illness
Maternal stress
Work outside the home
Trauma
Genetic
WHO 2000, Michie 2003, Barbosa-Cesnik 2003, Academy of Breastfeeding Medicine, 2004
Predisposing factors
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U.S. cohort of 946 Breastfeeding ♀
Telephone interviews
9.5% mastitis (64% diagnosed via telephone)
Average symptoms for 4.9 days
88% prescribed medications
– 86% antibiotics (46% cephelexin)
– 17% analgesics
• No cultures performed
Foxman 2002
Predisposing factors
• H/O mastitis with previous child (OR 4.0, 95% CI
2.94, 6.11)
• Cracks and nipple sores in same week as
mastitis (OR 3.4, 95% CI 2.04, 5.51)
• Antifungal nipple cream in 3 wk interval of
mastitis (OR 3.3, 95% CI 1.92, 5.62)
• Manual breast pump (for ♀ with no prior history)
(OR 3.3, 95% CI 1.92, 5.62)
• Feeding <10 times per day in same week
– (for 7-9 times OR 0.6, 95% CI 0.41, 1.01)
– For ≤ 6 tmes, OR 0.4, 95% CI 0.19, 0.82)
Foxman 2002
Foxman 2002
Foxman 2002
Microbiology
Microbiology
• Detection of pathogens difficult
– Usually nasal/skin flora
– Difficult to avoid contamination
• Milk culture
– Encouraged in hospital acquired, recurrent
mastitis, or no response in 2 days
WHO 2000
Microbiology
• Staph Aureus
• Coag neg staph
• Also, Group A and B βhemolytic Strep, E
Coli, H. flu
• MRSA
• Fungal infections
• TB where endemic – 1% of cases
MRSA in SF
Charlebois 2004
MRSA in SF
• SFGH
– Community Acquired: 70%
– Hospital Acquired: 50%
• Moffitt
– Community Acquired: 49%
– Hospital Acquired: 37%
• VA 45%
MRSA
• Risk factors for Community Acquired in SF
– Homelessness (p=.015)
– Injection drugs (p=.02)
• Difference in Strains
– Hospital: SCCmec Type 2
• More resistant
• May include Gent, Eryth, Quinolones, TMP/SMX, Clinda
– Community: SCCmec Type 4
• Susceptible to most ABX other than β lactams
• Carriage can be months to years
Charlebois 2004
Postpartum MRSA
• Case reports – Initially reported in Midwest
• NYC case-control study
– 8 cases (4 mastitis  3 breast abscesses)
– All CA-MRSA
• Resistant to β lactams
• Susceptible to Clinda, Flouroquinolones, TMPSMX, Gent, Rifampin, Tetracycline
– No transmission route identified
– Associated with GBBS (p=.03)
Saiman 2003
Fungal infections
• Based on case reports that anti-fungal cream
improves sx
• Case reports of cyptococcal infection
• Most common: Candida Albicans
– Genital tract  Newborn oral colonization
• May lead to nipple fissure
• Thought to be associated with deep, shooting
pains and nipple discomfort
• Most commonly treated with fluconozole to ♀,
oral nystatin to infant
Fungal infections:
Is Candida associated with shooting breast pain?
Case series on deep breast pain
– Isolated Candida in 5/20 (20%) patients
– Candida twice as often in superficial pain than bacteria
– Bacteria more often found in deep pain
• Case-control study, Australia
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61 nipple pain, 64 w/out nipple pain, 31 non-lactating
More Candida in pain(19%) than control (3%), p<.01
Also, S. Aureus assoc w/ pain (p<.001) and fissures (p<.001)
No Candida/S Aureus in non-lactating group
• Brazilian study showed 32% colonization in milk of Asx ♀
Amir 1996, Thomassen 1998, Carmichael 2001
Treatment
Treatment
• Supportive Therapy
– Rest, fluids, pain medication, anti-inflammatory
agents, encouragement
• Continue breast feeding
• Antibiotics that cover Staph and Strep
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Culture results
Severe symptoms
Nipple fissure
No improved sx after 12-24 hours of milk removal
• 86% of women in the U.S. get treated with Abx
WHO 2000, Foxman 2002
Treatment
(ACOG)
• Dicloxicillin 500 mg qid
• Erythromycin if PCN allergic
• If resistant to treatment penicillinaseproducing staph, then vancomycin or
cefotetan until 2 days after infection
subsides
• Minimum treatment 10-14 days
Treatment
(Alternative)
• Therapeutic U/S
• Accupunture
• Bella donna, Phytolacca, Chamomilla,
sulphur, Bellis perenis
• Cabbage leaves
• Avoid drinks like coffee with
methylxanthines, decreasing fat intake
Complications
(Other bad things related to
mastitis)
Abscess
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Most common in first 6 weeks
5-11% of mastitis cases
Affect future lactation in 10% of affected ♀
Treatment: I & D, U/S guided needle drainage
– Cohort of 19 ♀ with abscess: 18/19 successfully tx
with U/S-guided needle drainage
– Cohort of 30 ♀ (33 abscesses): Tx with needle drg
(no U/S), cure rate 82%, success assoc with smaller
volume of pus (4 ml vs 21.5 ml, p=.002) and
presented earlier (5 vs 8.5 days, p=/006)
Karstrup 1993, WHO 2000, Schwartz 2001
Abscess
• Prospective cohort128 BF ♀ with infection
– 102 mastitis (80%)
– 26 abscess (20%)
• No differences b/t groups by age, parity,
localization of infection, cracked nipples, +
milk cultures, mean lactation time
• Duration of symptoms: only independent
variable favoring abscess development
Dener 2003
Other Complications
• Distortion of breast
• Chronic inflammation
Michie 2003, WHO 2000
Granulomatous Mastitis
• Noncaseating granulomas in a lobular
distribution
• Differential Diagnosis
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TB mastitis
Foreign body
Fat necrosis
Autoimmune: sarcoid, erythema nodusum,
polyarthritis
• Presentation
– Unilateral Breast lump
– No infection identified at presentation
Heer 2003, Goldberg 2000
Granulomatous Mastitis
• Can mimic Breast Ca on clinical,
radiological, and cytological exams
• Diagnosis: Histology
• Treatment:
– Antibiotics not helpful
– Corticosteroids
– Excision biopsy
• Limited literature, but no clear association
with breast feeding, OCPs
Heer 2003, Goldberg 2000
Subclinical Mastitis
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No symptoms, usually unilateral
Reduction in milk output
Diagnosis: Increased milk sodium
Causes
– Milk stasis, poor nutrition, +/- bacteria
• Public Health implication
– Poor infant growth
– Increased risk of HIV transmission
• Natural Hx and clinical implication unclear
Michie 2003, Filteau 2003
Effect on Milk
Immune Factors
• IgA is predominant in milk
• Increased immune factors from both
plasma and local epithelial cells
• No adverse events documented in peds
– Poor growth documented likely related to poor
milk production
– Contradictory studies showing benefit or harm
• Interest in pediatric vaccine development
Michie 2003, Filteau 2003
Increased HIV transmission risk
• Milk VL increases 10-20 fold
• Alternating breast/bottle increased risk
• Role of free virus vs cell bound virus
unclear
• If ♀ must breast feed, then pump on
affected breast (pasteurize) and feed on
unaffected
• Subclinical mastitis: Problem -Lab dxs only
Michie 2003, Filteau 2003
Is there anything else?
Nipple piercing and mastitis
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Review of 10 case reports on Med-line
7 female, 3 male
5 right breast, 4 left, 1 both
Interval from piercing to treatment: 20.8 wks (2-52)
Symptoms: 1 week to several months
Complications: endocarditis, heart valve operation,
prosthesis infection, metal foreign body in breast tissue,
reoperation for recurrent infection, psychologic stress
secondary to Breast CA dxs
• Conclusion:
– Risk of nipple piercing under-documented and may be 10-20%
– Healing can take 6-12 months
Jacobs 2003
Take Home
• Mastitis can decrease motivation to
breast feed
• Remember Milk cultures if not getting
better
• OK to Breastfeed (except HIV+)