MASTITIS

Primarius Milos Pocekovac MD, PhD

 Prof  Ljiljana Bukarica MD, PhD

 Gordana Lukic MD

What is mastitis?

According to the World health organization mastitis is an inflammation of tissue of the breast which can but does not necessarily be connected with a bacterial infection.

Thera are different kinds of mastitis

Neonatal mastitis

Neonatal mastitis is a rare bacterial infection of the breast tissue. Usually it appears in one breast but it can happen that both breasts are affected. It appears several days after birth, usually during the first two weeks, and it is manifested as a swelling, redness and elevated temperature Most common cause is a Staphylococcus aureus infection, but sometimes the causative factor can be, Escherichia coli, Streptococcus group B, Peptostreptococcus, Bacteroides. In the early stages, antibiotics (flucosalicin) can control the infection, but if there is ultrasound confirmed collection an incision has to be made. Even though in this case it is easy to perform an incision of the change the procedure can lead to secondary amasty Also during the incision around the areola needs to be avoided, if possible and perform just an aspiration with a needle and introduce antibiotic therapy.  

Skin mastitis

Cellulitis is a rare infection of the breast and it is difficult to differentiate from the inflammatory breast cancer and benign erythema of the breast. Pain is the most characteristic symptom of cellulitis connected to redness, swelling and warmth. Treatment relays on antibiotics.  

Epidermoid cysts are discrete knots in the skin, which commonly are referred to as glands, or atheroma. There cysts are common in the skin of the breast but they can get infected and form a local abscess (see photo). The best treatment is a small incision followed by drainage, and not aspiration, due to the consistency of the content of the abscess.

mm1
After incision
mm2
Inflammation epidermoid cyst

Suppurate hidradenitis is a chronic inflammation aside from the gluteal, perianal, and ingvinal region it can appear in the axilla and under the areola. And any skin surface rich in glands. Infection followed by abscess formation in the lower parts of the beast and in the axilla. It appears more commonly in smokers. Therapy involves hygiene of the affected region, long term antibiotic use and in case of abscess formation a surgical excision.  

Nipple piercings

Placing piercings on the nipples can lead to subareolar abscess and sometimes infection of the areole, especially in smokers. One study confirmed piercings as the most significant factor in developing a sub areolar abscess in smokers.

Pilonidal sinuses

Pilonidal sinuses are reported in hair dressers and sheep keepers, due to the fact that lose hair pierced the skin and led to an inflammation.

Lactation mastitis

Mastitis is most commonly appearing after birth during the second and third week, and most studies showed that around 74% and 95% of cases appear in the first 12 weeks. Therefore, the inflammation can appear in any phase of lactation up to the second year. Abscess of the breast can appear in the six weeks after giving birth, but it can appear later on.

Lactation mastitis appears in 2,5% of women that breast feed.  

There are two most common causes of the appearance of mastitis: milk stasis and infection.

Milk stasis appears when mothers milk cannot drain adequately. This can happen after the faster milk production after the feeding and in any situation when the baby is not taking in the produced milk.

Causes that can lead to stasis are inefficient breastfeeding, poor connection between mothe and child, inconsistent timing of breastfeeding and blockage of the milk ducts. Mechanical factors like short frenulum (ankylogossia) in the child, tight and inappropriate bras can lead to stasis of milk.  

To avoid milk stasis, it is best to start the breast feeding immediately after birth. James Nelson 1753

James Nelson 1753

Therefore, if the blockage is not improved by massage and intensive breastfeeding, there is a progression of the disease into the next stage, noninfectious inflammation that is followed by pain and swelling in the area of obstruction, redness of the breast. Milk cultures can be taken at this stage and they should remain sterile, but the leukocyte count is elevated (over 1 000 000/ml milk).

Thompson et al in 1984. measured the leukocytes and bacterial counts in milk with clinical sings of mastitis and suggested the following classification:

Milk stasis
Mastitis non connected to infection
Infectous mastitis
<106 leukocytes
>106 leukocytes
>106 leukocytes
<103 bacteria
<103 bacteria
>103 bacteria
Therapy
Constant breast feeding
Additional removal of milk
Removal of milk and antibiotics

Still if there is no adequate removal of milk mastitis not connected to infection can lead to one with infection, and the appearance of an abscess.

The most common cause of infectious mastitis is Staphylococcus aureus, and afterwards it is S.albus, S.epidermidis. Other causative factors are rare: eg. Beta hemolytic Streptococcus (group A or B) or Escherichia coli, as well as MRSA. Very rare kinds of mastitis are connected to tuberculosis infection, Cryptococci, Candida, Typhoid fever.

Infection is most common during the first pregnancy and during the first 6 weeks of breast feeding, but it can also appear after the discontinuation of breastfeeding, Studies showed that women that gave birth between the ages of 21 and 35 have a higher chance to develop mastitis than women aged below 21 and over 35, most commonly between 30-34 years of age. Stress, trauma and malaise are contributing factors.

Incorrect technique of breastfeeding and trauma to the nipple leads to edema and increased number of bacteria on the skins surface. Bacteria can access the breast through a damaged nipple and infect the ducts.

Diagnosis is based on clinical symptoms and inflammation parameters. Ultra sound can detect a puss collection – abscess.

Clinical signs are pain, redness, edema, the breast is sensitive and red; if there is an abscess once can palpate a tumor with fluctuation and elevate mass, and skin over it is shiny and red. Also there are palpable lymph nodes in the axilla.  Patient can be toxic with elevated fever, tachycardia and elevated leukocyte levels. Antibiotics in the early stages (before abscess formation) usually can control the infection and prevent abscess formation

In patients that improve with the correct antibiotic therapy, ultrasound needs to be performed, to confirm if there are no puss collections and to exclude other etiology. Lactating breast and any other inflamed tissue, localizes the infection by forming a barrier of granulation tissue. This becomes the capsule and it fills up with puss.

If the abscess is verified on the ultrasound and the skin over is not damaged or necrotic it is possible to just aspirate the abscess. Combination of aspiration and antibiotics is usually effective an it is the treatment of choice. Aspirations should be repeated every 2 to 3 days or as long as the puss is present in the content of the syringe. The typical finding is that the aspirated fluid becomes serous and afterwards milky. If the skin over the abscess is damaged, and the puss is evident near the surface upon the ultrasound, it is necessary to perform a small incision after administering a local anesthetic to the skin, at the place with the most fluctuation (see photo). It is necessary to dress the wound every day until the spontaneous closure of the skin. If the skin is necrotic it should be removed, With the bigger lactation abscesses that can seize the entire breast drainage should be performed under general anesthesia.  Breastfeeding should be continued if possible, this will keep the ducts clear and healthy and help solve the infection. The child should not be affected with the bacteria present in the milk not the antibiotics used (fluocolacilin, amoksicilin or erythromycin). Patient that have the incision and drainage performed under general anesthesia are more commonly stopping the breastfeeding comparing to the ones that underwent the procedure under local anesthetic.

 

Case report

Patient, 28 years of age, 2 months after giving birth palpated a change 5cm in diameter. Ultrasound confirmed at around 10mm from the skin surface a puss collection, with thick walls and hypo echogenic and irregular wall thickness at 7mm.The surrounding tissue was also hypo echogenic structure.

Aspiration puncture was performed and thick puss collection was removed.

Content was sent to bacteriology and results showed a MRSA infection.

 Adequate antibiotic therapy was administered.

Patient 42 years of age, after giving birth for the first time had an elevated fever with right breast mastitis that spread to the left breast, as well as right hemi thorax and lumbar region. Antibiotic therapy was administered with Mipecid and than Longaceph and Vancomycin.

She was followed up by ultrasound for 7 days, there was no puss collection, and after the 7th day an abscess formed. (swab showed that it is a Staphyloccocus aureus infection).

Incision was performed at the place of fluctuation, at the joining place of the upper quadrants.

Predisposing factors for mastitis
age
Most common is 30-34. Years of age
Number of births
First time moms
Previous mastitis incidents
Diet
Adequate anti oxidans intake, vitamin E and A that lower the incidence of mastitis appearance.
Stress and fatigue
Women that have a fever or fatigue, but not enough evidence that it is a mastitisка
Trauma to the breast and nipple
Any kind of tissue damaging trauma and milk ducts can lead to mastitis.
Incorrect breastfeeding technique
Leads to edema and increased number of bacteria on the breast skin. Bacteria gains access to the breast trough the damaged nipple and infect the ducts.
Sudden stop in breastfeeding or milk overproduction
Leads to stasis and mastitis
Pressure on the breast
Tight bras and seat belts in the car
Genetic heritage
Positive family history, HLA-human leukocyte antigen status
Immune system
Low levels of milk cells and low levels of milk lactoferrins and low levels of milk lysosomes

Non lactation mastitis

Mastitis that are not connected to lactation can happen in tissue in the central part and peripheral parts of the breast.

Infection around the areola happens in young women at around 32 years of age. Most commonly it appears in smokers. Basic pathological process is periductal mastitis. Usual case is an aerobic and anaerobic bacterial infection as well as autoimmune reactions.  It appears as an infection around the areola or as an abscess collection or even as a periareolar fistulas. There is a common lymphadenopathy. Patients without the palpable tumor should be treated with antibiotics. If the clinical presentation is without improvement an ultrasound should be performed to determine if an abscess formed. If there is an abscess a needle aspiration needs to be performed with antibiotics therapy or an incision and drainage. After the resolution of inflammation in patient over 35 years of age a mammogram is indicated due to the possibility of a combination of infection and intraductal carcinoma. In approximately half of the patients the infection reoccurs. The only long term effective treatment for these women is surgical removal of all of the ducts.

Fistulas of the ductal canals

Fistulas of the ductal canals is a communication between the skin usually in periareolar region and in the main retroareolar breast canal. Fistulas usually appear after an abscess incision, even though they can appear after a spontaneous drainage of the inflammation collection or even after a biopsy of periductal mastitis. Patients usually complain of more common episodes of spontaneous drainage of the collections from the ductal canal over the skin. Surgery is indicated and it comprises of opening the fistula or excision.

Peripheral abscess of breast

Peripheral abscess not connected to lactation are rarer than periareolar absceses. Usually connected to other diseases, such as diabetes, rheumatoid arthritis, in patients under corticosteroid therapy and after trauma. Staphylococcus aureus is usually present and some of them contain anaerobic bacteria. Peripheral abscess is 3 times more common in menopausal women. Mammogram needs to be performed in the women over 35 years of age to exclude the possibility of cancer. Therapy remains the same by incision and drainage.  

Granulomatous lobular mastitis

Rare chronic inflammation disease first described in 1972 by Keslar and Volok. Etiology remain unknown, though it is assumed that the process is cause by an autoimmune disease or undetected microorganisms, use of contraceptive pills or reaction to giving birth. It presents as a though tumor mass, difficult to separate from breast cancer. Nipples can come back into the tissue and sinuses form. Regional enlargement of lymph nodes can appear in 15% of cases. Multiple recurrent abscesses can form. It is very difficult to differentiate this from the inflammatory and infectious mastitis.

Some patients describe the soft tissue and painful change and the skin over it can have an ulcer. It can appear in any region of the breast, rarely bilaterally. It is most common in young women in the 5 years after giving birth. This condition is more common in women of Asian descent and not in the Caucasian population. This condition can be connected to hyperprolactinemia. Rare causes are deficiency in Alpha 1 antitrypsin and Wagener’s granulomatosis.

Diagnosis is confirmed by biopsy or surgical excision.

Treatment includes the correct diagnosis and observation; no special measures need to be taken. The condition resolves itself in 6 to 12 weeks. Each abscess as it develops requires aspiration or a small incision and drainage. There is a tendency for the condition to reaper and it always comes to spontaneous resolution Some authors report that local excision with a without use of corticosteroids can give the best result. Methotrexate ad singular therapy in the dose of 7,5 mg per week can be efficient.

Pharmacological treatment of bacterial mastitis

Women that are breastfeeding are not egar to take medication due to disinformation that medications are harmful to the baby and mother. Though this fear is unjust, both doctors and new mothers need to be informed about the medications taken. Bacterial mastitis is an indication to take antimicrobial therapy and pain medication. Guidelines by the WHO and our own give out recommendations which medication to take in the case of active lactation, and with caution. Our National guide for rational use of antibiotics from 2018 recommend the following groups of medication during breastfeeding to be avoided: fluoroquinolones (ciprofloxacin, levofloxacin…), chloramphenicol, sulfonamides, tetracycline, and metronidazole with caution. Caution is needed with all antimicrobials that transfer to milk in significant amount: colchicine, linezolid and tigaracinin. As these are reserve antibiotics, they can be administered only after the isolated bacterial agent is sensitive only to these antibiotics. Pipemidic acid, uroantiseptic is contraindicated during breastfeeding.

Antibiotics

Australian guide recommends the use of antibiotics in the new moms after the appearance of mastitis that is not regressing in the first 12 to 24hr after starting the non-pharmacological treatment or if the first symptoms are moderate to severe. Oral antibiotics should be administered at least for 5 days. Improvement is expected after 2 to 3 days of treatment. If the improvement is slow, milk should be taken for culture and resistance to antibiotics should be determined. Considering the results change the antibiotic. During administration of antibiotics to breastfeeding moms pay attention to child, the adverse effects it can have on the baby. A change in the gastrointestinal flora is possible with symptoms of diarrhea and vomiting as well as a rash. If the condition in the woman worsens and she starts developing septic symptoms antibiotics should be started through an i.v. IV antibiotics should be administered at least for 48 hr or at least until clinical improvement. In the table below you can find the recommended antibiotics with the required dosages for treatment of mastitis

Choice of antibiotics with dosage regiment

Recommendation for antibiotic use
All of the recommended antibiotics are safe to ingest during breastfeeding
Administration
Antibiotic
Unwanted effects
Comments
Oral
Flucloxacillin (dicloxacillin) is not registered in Serbia) 500 mg every 6 hr , min for 5 days
Common: nausea, vomiting and diarrhea Rare: anaphylaxis, cholestatic jaundice
If the treatment lasts longer than 2 weeks do liver function tests
Intravenous
Flucloxacillin (dicloxacillin)
Penicillin allergy (excluded anaphylactic reaction)
Oral
Cephalexin 500 mg every 6 hr, min for 5 days
Common: nausea, diarrhea, vomiting and rash Rare: anaphylaxis
Cephalexin is prescribed in women allergic to penicillin but in 3-6% of cases there is a cross reaction to cephalosporin’s as well.
Intravenous
Cephasoline 2 gr every 8 hours
In cases of proved anaphylaxis to penicilins
Oral
Clindamycin 480 mg every 8 hours, minimum for 5 days
Common: nausea, diarrhea Rare: anaphylaxis, blood lineage disorders, jaundice
Used as the second line, when patient have certain penicillin use contraindications or cephalosporin of the first and second generation
Intravenous
Lincomycin 600mg every 8hours – not registered in Serbia
Intravenous
Vancomycin 1.5 gr every 12 hours
Common: thrombophlebitis Rare : skin reactions “red man syndrome
Use only if the pathogen is clindamycin and lincomycin resistant.
In case of MRSA isolation
Oral
Clindamycin 480 mg every 8 hours, for 5 days
Common: nausea, diarrhea, Rare: blood disorders, jaundice
An appearance of diarrhea, rash and cramps in babies to the change in the intestinal microbes.

Recommendation of the WHO for treatment of mastitis – oral antibiotics

Antibiotics
Дозни режим током 10-14 дана
Erythromycin
250 – 500 mg every 6hr
Flucloxacillin
250 mg every 6hr
Dicloxacillin
125-500 mg every 6hr
Amoxicillin
250-500 mg every 6hr
Cephalexin
250-500 mg every 6hr

WHO does not recommend penicillin and ampicillins due to more common resistance by S. aureus on these medications.

Beta lactams resistant penicillin such as Flucosalicine and Diclosalicine are the treatment of choice. Both suggested antibiotics are compatible with breastfeeding. Small amounts of  Flucosalicine and Diclosalicine are excreted through the milk but the concentration is not significant and should not cause adverse effects. Diclosalicine is not register in Serbia. First generation of cyclosporine are also an effective first line of defense and efficient in patient allergic to penicillin (excluding the acute allergic reactions). Only small amounts of cephalexins are excreted through the milk, so it is unlikely for them to cause adverse effects. Lincosamines, clindamycin are recommended in patient with positive anamnesis for allergies to penicillins and cephalosporin, as it is in patients with MRSA. Vancomycin is excreted in the milk in small amounts which excludes all adverse effects in babies. 

Mastitis caused but multiple resistant microorganisms (such as MRSA – hospital lineage) is treated after the arrival of resistance tests. Antibiotic with the most effectiveness is used, this is assessed through the minimal inhibitory concentration number (MIC90). It is necessary to evaluate the relation of the risk for the baby and benefit for the mother. In necessary cases when using the not recommended antibiotics for breastfeeding, it should be stopped until the resolution of the infection.

Pain management

Paracetamol is a safe pain medication during lactation and it is the treatment of choice for short term analgesia in mastitis with elevated fever. Usual daily dose is 500g to 1g, every 6hours. Maximum daily intake should not pass the amount of 4g daily. Our drug administration does not recommend the use of NSAILs like ibuprophens during breastfeeding

Most common pathogenic responses are presented in the table. Leading principles in treatment are the use of antibiotics as early as possible to prevent abscess formation, and if there is an infection is not solved after the treatment course, there is a suspicion of an already formed abscess or even a breast tumor.

Causative factor and specific therapy

Types of mastitis
Causes
Therapy for patient not allergic to penicillin’s
Therapy for patients with allergies to penicillin’s
Neonatal
Staphylococcus aureus (rare – Escherichia coli)
Flucloxacillin 500 mg, 4 times a day
Erythromycin 500 mg, 2 times a day
Lactation
Staphylococcus aureus rare Staphylococcus еpidermidis and Streptococci
Flucloxacillin 500 mg, 4 times a day
Erythromycin 500 mg, 2 times a day
Skin
Staphylococcus aureus
Flucloxacillin 500 mg, 4 times a day
Erythromycin 500 mg, 2 times a day
Non lactation
Staphylococcus aureus, Enterococci, anaerobic streptococci , Bacteroides spp.
Аmoкsicilin + clavuronic acid 375+125 mg , 4 times a day
Erythromycin 500 mg, 2 times a day + Metronidazole 200 mg, 4 times a day

IMPORTANT!

PLEASE HAVE THINGS YOU ARE IN THE VID!

This site is informative-educational. Our goal is to provide helpful information on symptoms and treatment of the disease to people with breast disorders. If you feel you have any of these symptoms, please contact your doctor. DO NOT use these therapies yourself without prior consultation with a doctor!

REFERENCES

1. World Health Organisation. Infectious Mastitis. Mastitis causes and Management. Geneva: WHO; 2000

2. William L, Weston and AT Lane. Neonatal dermatology. In: Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, Austen KF, editors. Dermatology in general medicine. vol 4. New York: Mc GrawHill;1993. p. 2941−60.

3. Harris JR. Lippman M.E., Morrow M. ,Osborne K.C.Diseases of the breast 5th ed.  2014.

4. Gollapalli V, Liao J, Dudakovic A, et al. Risk factors for development and recurrence of primary breast abscesses. J Am Coll Surg 2010;211:41.

5. Dixon JM. Breast infection. In: Dixon JM, ed. ABC of breast diseases. 4th ed. d. London: Wiley-Blackwell 2012.

6. Dixon JM. ABC of breast diseases: breast infection. Br J Med 1994; 309(6959): 946−9.

7. Loffler CA, Macdougall C. Update on prevalence and treatment of methicillin-resistant Staphylococcus aureus infections. Expert Rev Anti Infect Ther 2007;5(6):961-81.

8. Jonsson S, Pulkkinen MO. Mastitis today: incidence, prevention and treatment. Annales Chirurgiae Et Gynaecologiae.Supplementum, 1994, 208:84-87.

9. Kaufmann R, Foxman B. Mastitis among lactating women: Occurrence and risk factors. Social Science and Medicine, 1991, 33(6):701-705.

10. Kessler E, Wolloch Y. Granulomatous mastitis: a lesion clinically simulating carcinoma. Am J Clin Path/1972;58:642-646

11. Jorgensen MB, Nielsen DM. Diagnosis and treatment of granulomatous mastitis. Am J Med 1992;93:97-101

12. Patel RA, Strickland P, Sankara IR, Pinkston G, Many W, Rodriguez M: Idiopathic granulomatous mastitis: case reports and review of literature. J Gen Intern Med. 2009, 25 (3): 270-273.

13. Alper Akcan, A. Bahadir Öz,* Serap Dogan, Hülya Akgün, Muhammet Akyüz, Engin Ok, Mustafa Gök, and Tutkun Talih :Idiopathic Granulomatous Mastitis: Comparison of Wide Local Excision with or without Corticosteroid Therapy Breast Care (Basel). 9(2): 111–115. 2014 

14. Akbulut S, Yilmaz D, Bakir S. Methotrexate in the management of idiop athic granulomatous mastitis: review of 108 published cases and reports ts of four cases. Breast J 2011;17(6):661–668.

15. Hughes LE, Mansel RE, Webster DJT. Infections of the breast. In: Hughes LE, Mansel RE, Webster DJT, eds. Benign disorders and diseases of the breast: concepts and clinical management. 3rd ed. London: WB Saunders 2009.

Breast surgeon
Prim. Milos Pocekovac MD, PhD

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Неизмерно сам захвална Др Милошу, јер ми је скинуо највећу муку коју сам до тад имала у животу.
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