Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

lactational mastitis

1st line – effective milk removal and supportive care

Back
ACUTE
|
lactational mastitis
|
symptoms not severe or not prolonged: no systemic signs and negative culture
1st line – 

effective milk removal and supportive care

In an early stage, when signs and symptoms of mastitis have not been present for more than 12-24 hours, it may be possible to manage the condition without antibiotics.[41][43] However, antibiotics are required if the pain becomes severe or lasts more than 12-24 hours, if milk or blood culture is positive, or if there are any signs of systemic infection.

Breastfeeding should continue frequently (e.g., breastfeeding 8-12 times per day) to promote effective milk removal.

Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used.

The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). Counselling should include reassurance about the value of breastfeeding, and safety of continued breastfeeding (that the milk from the affected breast will not harm the infant where appropriate). Guidance on treatment, how to continue breastfeeding or expressing milk, and follow-up and continued support, is required.[1] These measures may require a lactation consultant.

The patient should be advised to increase her fluid intake, and try warm and/or cold compresses.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

1st line – empiric antibiotic therapy

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA excluded by culture or not prevalent locally
1st line – 

empiric antibiotic therapy

Antibiotics are indicated for patients with acute pain, severe symptoms, or symptoms lasting more than 12-24 hours; fever or any other signs of systemic infection; or positive microbiology studies.

As Staphylococcus aureus is the most common pathogen, antibiotics with activity against staphylococci should be used. If MRSA can be excluded by culture, or if MRSA is not prevalent locally, 10-14 days of oral dicloxacillin, cloxacillin, or flucloxacillin (depending on availability) is the initial choice.[40] Cefalexin, a first-generation cephalosporin, may also be considered, but it has a broad spectrum of coverage and is more likely to promote the development of MRSA.​[45]

Cefalexin may be prescribed for patients with a penicillin allergy (although it should be used with caution as a minority of patients may experience cross-reactivity between penicillins and cephalosporins); clindamycin is appropriate for patients with severe penicillin hypersensitivity.[40]

Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities.

An isolated nipple infection can be treated with topical antimicrobial therapy.

Treatment course: 10-14 days.

Primary options

flucloxacillin: 250-500 mg orally four times daily

OR

dicloxacillin: 250-500 mg orally four times daily

OR

cloxacillin: 250-500 mg orally four times daily

Secondary options

cefalexin: 500 mg orally four times daily

OR

clindamycin: 300-450 mg orally four times daily

Plus – effective milk removal and supportive care

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA excluded by culture or not prevalent locally
Plus – 

effective milk removal and supportive care

Treatment recommended for ALL patients in selected patient group

Breastfeeding should continue frequently (e.g., breastfeeding 8-12 times per day) to promote effective milk removal.

Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used.

The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). Counselling should include reassurance about the value of breastfeeding, and safety of continued breastfeeding (that the milk from the affected breast will not harm the infant where appropriate). Guidance on treatment, how to continue breastfeeding or expressing milk, and follow-up and continued support, is required.[1] These measures may require a lactation consultant.

The patient should be advised to increase her fluid intake, and try warm and/or cold compresses.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Consider – antifungal therapy (for mother and infant) for nipple candidiasis

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA excluded by culture or not prevalent locally
Consider – 

antifungal therapy (for mother and infant) for nipple candidiasis

Additional treatment recommended for SOME patients in selected patient group

If nipple candidiasis is diagnosed, both mother and infant must be treated simultaneously.

A topical antifungal should be used in the mother, combined with a topical application of an antifungal suspension in the infant’s mouth.

Treatment course: continue for 48 hours after resolution of symptoms.

Primary options

nystatin topical: mother: (100,000 units/g) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

OR

miconazole topical: mother: (2%) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

OR

ketoconazole topical: mother: (2%) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

2nd line – alternative antibiotic guided by culture sensitivities or further work-up

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA excluded by culture or not prevalent locally
2nd line – 

alternative antibiotic guided by culture sensitivities or further work-up

Infections should begin to respond within 48 hours. If there is no improvement within this time frame, breastmilk culture and assay of antibiotic sensitivities should be ordered, and the possibility of alternative diagnoses considered. Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities.

If the infection is worsening despite oral therapy, intravenous vancomycin may be considered. Alternatively, other antibiotics with activity against MRSA may be used, but experience with these other agents in treating mastitis is limited.

In refractory cases an ultrasound scan should be performed looking for possible underlying abscess, a biopsy should be considered, and cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-resistant pathogen.

If a fistula is detected, it needs to be excised (fistulectomy) along with its feeding duct.[53]

Antibiotic treatment course: 10-14 days.

Primary options

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 4 g/day

Plus – effective milk removal and supportive care

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA excluded by culture or not prevalent locally
Plus – 

effective milk removal and supportive care

Treatment recommended for ALL patients in selected patient group

Breastfeeding should continue frequently (e.g., breastfeeding 8-12 times per day) to promote effective milk removal.

Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used.

The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). Counselling should include reassurance about the value of breastfeeding, and safety of continued breastfeeding (that the milk from the affected breast will not harm the infant where appropriate). Guidance on treatment, how to continue breastfeeding or expressing milk, and follow-up and continued support, is required.[1] These measures may require a lactation consultant.

The patient should be advised to increase her fluid intake, and try warm and/or cold compresses.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Consider – antifungal therapy (for mother and infant) for nipple candidiasis

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA excluded by culture or not prevalent locally
Consider – 

antifungal therapy (for mother and infant) for nipple candidiasis

Additional treatment recommended for SOME patients in selected patient group

If nipple candidiasis is diagnosed, both mother and infant must be treated simultaneously.

A topical antifungal should be used in the mother, combined with a topical application of an antifungal suspension in the infant’s mouth.

Treatment course: continue for 48 hours after resolution of symptoms.

Primary options

nystatin topical: mother: (100,000 units/g) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

OR

miconazole topical: mother: (2%) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

OR

ketoconazole topical: mother: (2%) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

1st line – non-beta-lactam antibiotic

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA confirmed by culture or prevalent locally
1st line – 

non-beta-lactam antibiotic

Antibiotics are indicated for patients with acute pain, severe symptoms, or symptoms lasting more than 12-24 hours; fever or any other signs of systemic infection; or positive microbiology studies.

If MRSA has been confirmed by culture, or if MRSA is known to be prevalent locally, clindamycin or trimethoprim/sulfamethoxazole may be appropriate treatment options for community-acquired MRSA (CA-MRSA).[48] Trimethoprim/sulfamethoxazole should not be given if the mother is breastfeeding a jaundiced infant (because of the risk of kernicterus), a premature infant, or a baby aged less than 30 days.[40][49]​ Doxycycline can also be used for CA-MRSA infections. It was previously thought that the mother must not breastfeed and would need to pump milk to maintain supply during the antibiotic course. However short-term use of doxycycline may be considered acceptable during lactation in courses up to 21 days if no alternative is available.[50][51]

The decision to start oral or intravenous antimicrobials at the time of initial presentation depends on clinical judgment and the severity of illness.

Trimethoprim/sulfamethoxazole is an acceptable choice if hospital-acquired MRSA is suspected. An alternative antibiotic is required if the mother is breastfeeding a jaundiced infant (because of the risk of kernicterus), a premature infant, or a baby aged less than 30 days.[40][49]

Vancomycin may be indicated first-line in hospitalised patients with severe infection. This covers hospital-acquired MRSA.

Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities.

An isolated nipple infection can be treated with topical antimicrobial therapy.

Treatment course: 10-14 days.

Primary options

clindamycin: 300-450 mg orally four times daily

OR

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily

OR

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 4 g/day

Secondary options

doxycycline: 100 mg orally twice daily

Plus – effective milk removal and supportive care

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA confirmed by culture or prevalent locally
Plus – 

effective milk removal and supportive care

Treatment recommended for ALL patients in selected patient group

Generally, breastfeeding should continue frequently (e.g., breastfeeding 8-12 times per day) to promote effective milk removal.

Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used.

The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). Counselling should include reassurance about the value of breastfeeding, and safety of continued breastfeeding (that the milk from the affected breast will not harm the infant where appropriate). Guidance on treatment, how to continue breastfeeding or expressing milk, and follow-up and continued support, is required.[1] These measures may require a lactation consultant.

The patient should be advised to increase her fluid intake, and try warm and/or cold compresses.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Consider – antifungal therapy (for mother and infant) for nipple candidiasis

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA confirmed by culture or prevalent locally
Consider – 

antifungal therapy (for mother and infant) for nipple candidiasis

Additional treatment recommended for SOME patients in selected patient group

If nipple candidiasis is diagnosed, both mother and infant must be treated simultaneously.

A topical antifungal should be used in the mother, combined with a topical antifungal suspension for use in the infant’s mouth.

Treatment course: continue for 48 hours after resolution of symptoms.

Primary options

nystatin topical: mother: (100,000 units/g) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

OR

miconazole topical: mother: (2%) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

OR

ketoconazole topical: mother: (2%) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

2nd line – alternative antibiotic guided by culture sensitivities or further work-up

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA confirmed by culture or prevalent locally
2nd line – 

alternative antibiotic guided by culture sensitivities or further work-up

Infections should begin to respond to antibiotics within 48 hours. If there is no improvement within this time frame, breastmilk culture and assay of antibiotic sensitivities should be ordered, and the possibility of alternative diagnoses considered. Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities.

If the infection is worsening despite oral therapy, intravenous vancomycin may be considered. Alternatively, other antibiotics with activity against MRSA may be used, but experience with these other agents in treating mastitis is limited.

In refractory cases an ultrasound scan should be performed looking for possible underlying abscess, a biopsy should be considered, and cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-resistant pathogen.

If a fistula is detected it needs to be excised (fistulectomy) along with its feeding duct.[53]

Antibiotic treatment course: 10-14 days.

Primary options

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 4 g/day

Plus – effective milk removal and supportive care

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA confirmed by culture or prevalent locally
Plus – 

effective milk removal and supportive care

Treatment recommended for ALL patients in selected patient group

Generally, breastfeeding should continue frequently (e.g., breastfeeding 8-12 times per day) to promote effective milk removal.

Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used.

The patient should receive support in terms of counselling and breastfeeding advice, and analgesia if necessary (e.g., paracetamol, ibuprofen). Counselling should include reassurance about the value of breastfeeding, and safety of continued breastfeeding (that the milk from the affected breast will not harm the infant where appropriate). Guidance on treatment, how to continue breastfeeding or expressing milk, and follow-up and continued support, is required.[1] These measures may require a lactation consultant.

The patient should be advised to increase her fluid intake, and try warm and/or cold compresses.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Consider – antifungal therapy (for mother and infant) for nipple candidiasis

Back
ACUTE
|
lactational mastitis
|
symptoms severe or prolonged or systemic signs: MRSA confirmed by culture or prevalent locally
Consider – 

antifungal therapy (for mother and infant) for nipple candidiasis

Additional treatment recommended for SOME patients in selected patient group

If nipple candidiasis is diagnosed, both mother and infant must be treated simultaneously.

A topical antifungal should be used in the mother, combined with a topical application of an antifungal suspension for use in the infant’s mouth.

Treatment course: continue for 48 hours after resolution of symptoms.

Primary options

nystatin topical: mother: (100,000 units/g) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

OR

miconazole topical: mother: (2%) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

OR

ketoconazole topical: mother: (2%) apply to the affected area(s) twice daily

and

nystatin: infant: (100,000 units/mL) 2 mL orally four times daily

non-lactational mastitis

1st line – empiric antibiotic therapy

Back
ACUTE
|
non-lactational mastitis
|
MRSA excluded by culture or not prevalent locally
1st line – 

empiric antibiotic therapy

Differentiating between infectious and non-infectious non-lactational mastitis is difficult. Therefore, antimicrobial therapy, without any observation period, is the initial treatment for all patients presenting with non-lactational mastitis.

As Staphylococcus aureus is the most common pathogen, antibiotics with activity against staphylococci should be used. If MRSA can be excluded by culture, or if MRSA is not prevalent locally, 10-14 days of oral dicloxacillin, cloxacillin, or flucloxacillin (depending on availability) is the initial choice.[40] Cefalexin, a first-generation cephalosporin, may also be considered, but it has a broad spectrum of coverage and is more likely to promote the development of MRSA.​[45]

Cefalexin may be prescribed for patients with a penicillin allergy (although it should be used with caution as a minority of patients may experience cross-reactivity between penicillins and cephalosporins); clindamycin is appropriate for patients with severe penicillin hypersensitivity.[40]

Antibiotic therapy may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities.

An isolated nipple infection can be treated with topical antimicrobial therapy.

Treatment course: 10-14 days.

Primary options

flucloxacillin: 250-500 mg orally four times daily

OR

dicloxacillin: 250-500 mg orally four times daily

OR

cloxacillin: 250-500 mg orally four times daily

Secondary options

cefalexin: 500 mg orally four times daily

OR

clindamycin: 300-450 mg orally four times daily

Plus – switch to appropriate therapy for underlying cause if needed

Back
ACUTE
|
non-lactational mastitis
|
MRSA excluded by culture or not prevalent locally
Plus – 

switch to appropriate therapy for underlying cause if needed

Treatment recommended for ALL patients in selected patient group

Persistent infection despite the appropriate use of antibiotics and drainage procedures should prompt further investigation with fungal cultures. Choice of antifungal therapy depends on the result of the culture.

For post-operative wound infections, a surgeon should be consulted.

Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body.

Tuberculosis (TB) of the breast is rare and requires anti-TB therapy under specialist guidance. A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention.[6] See Extrapulmonary tuberculosis (Management).​

For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice. However there is evidence to suggest that surgical management, with or without corticosteroids, results in high complete remission rates.[52]

Consider – supportive care

Back
ACUTE
|
non-lactational mastitis
|
MRSA excluded by culture or not prevalent locally
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Supportive care includes analgesia if required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

2nd line – alternative antibiotic guided by further investigations or further work-up

Back
ACUTE
|
non-lactational mastitis
|
MRSA excluded by culture or not prevalent locally
2nd line – 

alternative antibiotic guided by further investigations or further work-up

Infections should begin to respond within 48 hours.

If the infection is worsening despite oral therapy or if the infection is severe and occurs in a hospitalised patient, intravenous vancomycin may be considered.

Alternatively, other antibiotics with activity against MRSA may be used, but experience with these other agents in treating mastitis is limited.

In refractory cases an ultrasound should be performed looking for possible underlying abscess, a biopsy should be considered, and cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-resistant pathogen.

If a fistula is detected it needs to be excised (fistulectomy) along with its feeding duct.[53]

Antibiotic treatment course: 10-14 days.

Primary options

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 4 g/day

Plus – switch to appropriate therapy for underlying cause if needed

Back
ACUTE
|
non-lactational mastitis
|
MRSA excluded by culture or not prevalent locally
Plus – 

switch to appropriate therapy for underlying cause if needed

Treatment recommended for ALL patients in selected patient group

Persistent infection despite the appropriate use of antibiotics and drainage procedures should prompt further investigation with fungal cultures. Choice of antifungal therapy depends on the result of the culture.

For post-operative wound infections, a surgeon should be consulted.

Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body.

Tuberculosis (TB) of the breast is rare and requires anti-TB therapy under specialist guidance. A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention.[6] See Extrapulmonary tuberculosis (Management).​

For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice. However there is evidence to suggest that surgical management, with or without corticosteroids, results in high complete remission rates.[52]

Consider – supportive care

Back
ACUTE
|
non-lactational mastitis
|
MRSA excluded by culture or not prevalent locally
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Supportive care includes analgesia if required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

1st line – non-beta-lactam antibiotic

Back
ACUTE
|
non-lactational mastitis
|
MRSA confirmed by culture or prevalent locally
1st line – 

non-beta-lactam antibiotic

Differentiating between infectious and non-infectious non-lactational mastitis is difficult. Therefore, antimicrobial therapy, without any observation period, is the initial treatment for all patients presenting with non-lactational mastitis.

If MRSA has been confirmed by culture, or if MRSA is known to be prevalent locally, clindamycin or trimethoprim/sulfamethoxazole may be appropriate treatment options for community-acquired MRSA (CA-MRSA).[48] Doxycycline can also be used for CA-MRSA infections.

The decision to start oral or intravenous antimicrobials at the time of initial presentation depends on clinical judgment and the severity of illness.

In areas where MRSA is common, local resistance patterns need to be considered in the choice of antibiotics.

Vancomycin may be indicated first-line in hospitalised patients with severe infection. This covers hospital-acquired MRSA.

An isolated nipple infection can be treated with topical antimicrobial therapy.

Treatment course: 10-14 days.

Primary options

clindamycin: 300-450 mg orally four times daily

OR

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily

OR

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 4 g/day

Secondary options

doxycycline: 100 mg orally twice daily

Plus – switch to appropriate therapy for underlying cause if needed

Back
ACUTE
|
non-lactational mastitis
|
MRSA confirmed by culture or prevalent locally
Plus – 

switch to appropriate therapy for underlying cause if needed

Treatment recommended for ALL patients in selected patient group

Persistent infection despite the appropriate use of antibiotics and drainage procedures should prompt further investigation with fungal cultures. Choice of antifungal therapy depends on the result of the culture.

For post-operative wound infections, a surgeon should be consulted.

Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body.

Tuberculosis (TB) of the breast is rare and requires anti-TB therapy under specialist guidance. A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention.[6] See Extrapulmonary tuberculosis (Management)​.

For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice. However there is evidence to suggest that surgical management, with or without corticosteroids, results in high complete remission rates.[52]

Consider – supportive care

Back
ACUTE
|
non-lactational mastitis
|
MRSA confirmed by culture or prevalent locally
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Supportive care includes analgesia if required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

2nd line – alternative antibiotic guided by further investigations or further work-up

Back
ACUTE
|
non-lactational mastitis
|
MRSA confirmed by culture or prevalent locally
2nd line – 

alternative antibiotic guided by further investigations or further work-up

Infections should begin to respond within 48 hours. If the infection is worsening despite oral therapy, intravenous vancomycin should be considered instead.

Alternatively, other antibiotics with activity against MRSA may be used (but experience with these other agents in treating mastitis is limited).

In refractory cases an ultrasound scan should be performed looking for possible underlying abscess, a biopsy should be considered, and cultures should be performed to exclude atypical micro-organisms and/or a multi-drug-resistant pathogen.

If a fistula is detected it needs to be excised (fistulectomy) along with its feeding duct.[53]

Antibiotic treatment course: 10-14 days.

Primary options

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 4 g/day

Plus – switch to appropriate therapy for underlying cause if needed

Back
ACUTE
|
non-lactational mastitis
|
MRSA confirmed by culture or prevalent locally
Plus – 

switch to appropriate therapy for underlying cause if needed

Treatment recommended for ALL patients in selected patient group

Persistent infection despite the appropriate use of antibiotics and drainage procedures should prompt further investigation with fungal cultures. Choice of antifungal therapy depends on the result of the culture.

Tuberculosis (TB) of the breast is rare and requires anti-TB therapy under specialist guidance. A lack of response to anti-TB therapy or a diffusely deformed breast with draining sinuses may require surgical intervention.[6] See Extrapulmonary tuberculosis (Management).​

For post-operative wound infections, a surgeon should be consulted.

Bacterial contamination of a breast implant or any infected foreign body (e.g., nipple ring) is an indication for removal of the foreign body.

For granulomatous mastitis (idiopathic granulomatous inflammation), glucocorticosteroids are the treatment of choice. However there is evidence to suggest that surgical management, with or without corticosteroids, results in high complete remission rates.[52]

Consider – supportive care

Back
ACUTE
|
non-lactational mastitis
|
MRSA confirmed by culture or prevalent locally
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Supportive care includes analgesia if required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

breast abscess

1st line – surgical intervention

Back
ACUTE
|
breast abscess
|
MRSA excluded by culture or not prevalent locally
1st line – 

surgical intervention

Needle aspiration (18- to 19-gauge needle) with local anaesthesia, with or without ultrasound guidance, can be used to drain an abscess.[5][30][54]​​​​ For complete drainage of the abscess, multiple aspirations may be necessary (daily aspiration for 5-7 days). Aspirated fluid can be sent for culture to guide subsequent antibiotic therapy.

The risk of failure for needle aspiration is greater with abscesses >5 cm in diameter.[5]​​[54]​​ If complete clearance of frank pus is problematic with fine needle aspiration, management options include the use of a larger needle, surgical drainage, or repeat percutaneous catheter drainage (drainage without placing an indwelling catheter). Incision and drainage is reserved for patients in whom aspiration fails after several attempts (guidance suggests at least 3-5 attempts) and/or for multiloculated or large abscesses.[30][54][55]​​ Repeat percutaneous drainage may also be considered for large collections. Repeat drainage appears to be as effective as indwelling catheter drainage, but with reduced risks and increased patient comfort.[30]

Some evidence exists for the application of a negative suction drain through a mini periareolar incision. One retrospective study of women with lactational breast abscess reported that negative suction pressure was associated with shorter hospital stay and a higher rate of continuation of breastfeeding than incision and drainage.[56]

Plus – intravenous or oral antibiotic with activity against methicillin-sensitive staphylococci

Back
ACUTE
|
breast abscess
|
MRSA excluded by culture or not prevalent locally
Plus – 

intravenous or oral antibiotic with activity against methicillin-sensitive staphylococci

Treatment recommended for ALL patients in selected patient group

Antimicrobial therapy is prescribed in addition to drainage of the abscess. Without drainage of the abscess, antimicrobial therapy is unlikely to be successful because the wall of the abscess protects bacteria from the action of the antibiotics.[1]

If MRSA can be excluded, or if MRSA is not prevalent locally, a breast abscess can be treated with an oral or intravenous antibiotic that is active against methicillin-sensitive staphylococci. However, studies have found that community-acquired MRSA (CA-MRSA) is a significant pathogen among women admitted to hospital with puerperal breast abscess.[10][57]​​ In cases of suspected or confirmed CA-MRSA, or in a patient with a penicillin allergy, trimethoprim/sulfamethoxazole, or doxycycline, or clindamycin can be used. Trimethoprim/sulfamethoxazole should not be given if the mother is breastfeeding a jaundiced infant (because of the risk of kernicterus), a premature infant, or a baby aged less than 30 days.[40][49]​​ It was previously thought that mothers prescribed doxycycline must not breastfeed and would need to pump milk to maintain supply during the antibiotic course. However short-term use of doxycycline may be considered acceptable during lactation in courses up to 21 days if no alternative is available.[50][51]

Intravenous vancomycin may be used in more severe cases and in hospitalised patients where hospital-acquired MRSA is suspected. It is important to refer to local antibiotic prescribing policies and, where possible, be guided by sensitivities on culture.

Treatment course: 7-10 days.

Primary options

dicloxacillin: 500 mg orally four times daily

OR

cefalexin: 500 mg orally four times daily

OR

doxycycline: 100 mg orally twice daily

OR

clindamycin: 300-450 mg orally four times daily

OR

flucloxacillin: 250-500 mg orally four times daily; 500-2000 mg intravenously every 6 hours

OR

oxacillin: 1-2 g intravenously every 4-6 hours

OR

nafcillin: 1-2 g intravenously every 4-6 hours

OR

cefazolin: 1-2 g intravenously every 8 hours

Plus – re-assess diagnosis and treatment

Back
ACUTE
|
breast abscess
|
MRSA excluded by culture or not prevalent locally
Plus – 

re-assess diagnosis and treatment

Treatment recommended for ALL patients in selected patient group

The diagnosis and treatment will need to be re-assessed, with adjustment made if there is no response to antibiotics within 48 hours.

Antibiotic therapy should be adjusted depending on the specific pathogen(s) isolated from aspirated fluid.

Consider – supportive care

Back
ACUTE
|
breast abscess
|
MRSA excluded by culture or not prevalent locally
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Supportive care includes analgesia if required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

1st line – surgical intervention

Back
ACUTE
|
breast abscess
|
MRSA confirmed by culture or prevalent locally
1st line – 

surgical intervention

Needle aspiration (18- to 19-gauge needle) with local anaesthesia, with or without ultrasound guidance, can be used to drain an abscess.​[5][30][54]​​​​ For complete drainage of the abscess, multiple aspirations may be necessary (daily aspiration for 5-7 days). Aspirated fluid can be sent for culture to guide subsequent antibiotic therapy.

The risk of failure for needle aspiration is greater with abscesses >5 cm in diameter.[5]​​[54]​​ If complete clearance of frank pus is problematic with fine needle aspiration, management options include the use of a larger needle, surgical drainage, or repeat percutaneous catheter drainage (drainage without placing an indwelling catheter). Incision and drainage is reserved for patients in whom aspiration fails after several attempts (guidance suggests at least 3-5 attempts) and/or for multiloculated or large abscesses.[30][54][55]​​ Repeat percutaneous drainage may also be considered for large collections. Repeat drainage appears to be as effective as indwelling catheter drainage, but with reduced risks and increased patient comfort.[30]

Some evidence exists for the application of a negative suction drain through a mini periareolar incision. One retrospective study of women with lactational breast abscess reported that negative suction pressure was associated with shorter hospital stay and a higher rate of continuation of breastfeeding than incision and drainage.[56]

Plus – non-beta-lactam antibiotic

Back
ACUTE
|
breast abscess
|
MRSA confirmed by culture or prevalent locally
Plus – 

non-beta-lactam antibiotic

Treatment recommended for ALL patients in selected patient group

In cases of suspected or confirmed community-acquired MRSA, or in a patient with a penicillin allergy, trimethoprim/sulfamethoxazole, or doxycycline, or clindamycin can be used.

Trimethoprim/sulfamethoxazole should not be given if the mother is breastfeeding a jaundiced infant (because of the risk of kernicterus), a premature infant, or a baby aged less than 30 days.[40][49]​​ It was previously thought that mothers prescribed doxycycline must not breastfeed and would need to pump milk to maintain supply during the antibiotic course. However short-term use of doxycycline may be considered acceptable during lactation in courses up to 21 days if no alternative is available.[50][51]

The decision to start oral or intravenous antimicrobials at the time of initial presentation depends on clinical judgement and the severity of illness. Intravenous vancomycin may be used in more severe cases and in hospitalised patients where hospital-acquired MRSA is suspected. It is important to refer to local antibiotic prescribing policies and, where possible, be guided by sensitivities on culture.

Culture of aspirated fluid can guide subsequent antibiotic adjustment.

Treatment course: 7-10 days.

Primary options

clindamycin: 300-450 mg orally four times daily

OR

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily

OR

doxycycline: 100 mg orally twice daily

OR

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 4g/day

Plus – re-assess diagnosis and treatment

Back
ACUTE
|
breast abscess
|
MRSA confirmed by culture or prevalent locally
Plus – 

re-assess diagnosis and treatment

Treatment recommended for ALL patients in selected patient group

The diagnosis and treatment will need to be re-assessed, with adjustment made if there is no response to antibiotics within 48 hours.

Antibiotic therapy should be adjusted depending on the specific pathogen(s) isolated from aspiration fluid.

Consider – supportive care

Back
ACUTE
|
breast abscess
|
MRSA confirmed by culture or prevalent locally
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Supportive care includes analgesia if required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

ONGOING

breast abscess post acute intervention

1st line – consideration of further surgical intervention

Back
ONGOING
|
breast abscess post acute intervention
1st line – 

consideration of further surgical intervention

After the acute phase has subsided, chronically infected tissue and the major lactiferous duct associated with the abscess leading to the nipple may need to be excised.[30]

If the incision does not interfere with breastfeeding, a lactating mother can continue to nurse. If the incision does interfere with nursing, milk can be regularly removed with a breast pump.

recurrence of mastitis and/or breast abscess

1st line – re-assessment and treatment

Back
ONGOING
|
recurrence of mastitis and/or breast abscess
1st line – 

re-assessment and treatment

Recurrence may occur with delayed therapy, a short course of therapy, inappropriate therapy, and in Staphylococcus carriers. Recurrent mastitis or persistence of a mass after therapy may be due to a breast abscess or underlying breast lesion.

Granulomatous mastitis has a high recurrence rate.

Smoking cessation should also be encouraged, to minimise the risk of recurrence.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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