Mastitis and Breast Abcess

This guideline applies to adults over 18 years and females of childbearing potential.

Introduction

This is common in lactating women and does not necessarily mean infection is present.
It can be caused by poor positioning/latching or restricted feeding.
Periductal mastitis – usually in women aged 30-50years, often recurrent and strongly linked to smoking.
Inflammatory breast cancer – is very uncommon but needs to be excluded if ‘mastitis’ fails to resolve with treatment.

·Skin dimpling (peau d’orange)

·Mastitis not responsive to antibiotics after 10 days

·Mastitis not associated with breastfeeding or another cause

·Breast Sepsis - systemically unwell, obvious abscess, or necrotic/compromised skin

History:

Breastfeeding status – missed/interrupted feedings, poor milk removal (feeling full after feeds), inappropriate use of breast pump (flange size should be matched to breast teat size)
Fever/flu-like symptoms
Breast pain
Predisposing factors (not postpartum) – trauma, piercings, smoking

Examination:

Blocked duct – palpable lump with well defined margins. No fever. May have blocked nipple pore
Infective mastitis – tender red or pink, hot swollen wedge-shaped are of breast; chills; temp 38.0C or higher; flu-like symptoms
Inflammatory breast cancer – diffuse erythema and oedema involving 1/3^rd or more of the breast; no fever; is often accompanied by peau d’orange; not responsive to abx after 10/7 and not associated with breastfeeding or another cause.

Lactational Mastitis, Abcess or Blocked duct:

1. Admit to general surgery if patient has: severe cellulitis, an obvious abcess, sepsis or has cellulitis not responding to oral antibiotics

2. Reassure the patient although painful, breastfeeding can continue.

3. Advise about effective milk drainage:

Feed frequently, offering the affected breast first.
Use warm compresses and gentle massage before feeding to stimulate the let-down reflex.
Ensure attachment is optimal and direct the baby’s chin towards the blocked area while breastfeeding.
Change feeding positions to help empty the breast.
Gently, but firmly, massage the lump towards the nipple during and after feeds.
If pain is inhibiting let-down, begin feeding on the unaffected side and then switch to the affected breast.
Ensure complete emptying of the breast.
- Hand expressing under a warm shower may be effective.
- Failure to remove milk from the affected breast may predispose the patient to mastitis or abscess.
A covered cold pack, applied for a few minutes following a feed, may relieve pain and inflammation. A clean, disposable nappy, filled with water and frozen, is a cheap and reusable cold pack option.

4. Advise rest, hydration and help from friends and relatives.

5. Advise OTC analgesia i.e. paracetamol & Ibuprofen

6. Give information on breastfeeding support groups and links plus advise the patient to contact their health visitor or community midwife if needed

7. For mastitis - If symptoms do not resolve within 24hrs start antibiotics

(both safe with breastfeeding)
- Flucloxacillin 500mg QDS 10-14/7
- Clarithromycin 500mg BD 10-14/7 (if penicillin allergy)
Advise to seek medical advice if sx fail to resolve after 48hrs as typically response to treatment is rapid.

Non-lactational mastitis/abcess:

Admit to general surgery if patient has severe cellulitis, an obvious abcess, sepsis or has cellulitis not responding to oral antibiotics
If over 50yrs refer 2ww breast (as well as starting abx etc)
If breast infection associated with implants admit to general surgery or ring microbiology for advice.
Advise OTC analgesia i.e. paracetamol & Ibuprofen
Prescribe an antibiotic for ALL patients with non-lactational mastitis:

Co-amoxiclav 625mg TDS 10-14/7 or
Clarithromycin 500mg BD AND metronidazole 400mg BD 10-14/7 (if penicillin allergy)
See NHS Cornwall and Isles of Scilly Formulary – Infections
Advise to seek medical advice if sx fail to resolve after 48hrs as typically response to treatment is rapid or if a breast abcess develops.
Advise the patient to: stop smoking and improve glycaemic control (if diabetic)

There is no advice and guidance service for breast surgery.

Admit to general surgery:

Refer 2ww:

If non-lactational mastitis over 50yrs refer 2ww breast (as well as starting abx etc)
Suspicion of inflammatory breast cancer

For professionals:

For professionals:

Review date	5 January 2024
Next review date	5 January 2026
Clinical editor	Dr Madeleine Attridge
Contributors	Mr Iain Brown (Consultant Breast surgeon) Miss Polly King (consultant Breast surgeon) Dr Rebecca Osborne (GPwSI Breast)