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Mastitis: Understanding treatment options and principles

Pain, Women's Health, Infant and Children | April 30, 2015 | Author: The Super Pharmacist

women, infant

Mastitis: Understanding treatment options and principles

Mastitis is a disorder involving the inflammation of breast tissue. It is a condition that may cause benign (i.e. non-cancerous) masses in the breasts of affected women. There are two main types of mastitis in humans:

  • Puerperal mastitis, or mastitis that affects lactating women, or
  • Non-puerperal mastitis, or mastitis that affects the non-lactating breasts of women without infants

Puerperal mastitis is regarded as the more common form of this condition.The non-puerperal form is rarer. Mastitis may be unilateral, (mastitis that develops in just one breast), or bilateral (mastitis that is initially confined to one breast, but is seen to develop in the other over time).

Puerperal Mastitis

The symptoms of puerperal mastitis may include:

  • Breast pain
  • Breast 'thickening' and/or swelling due to the development of inflammatory lesions in the breast
  • Fever
  • Increased tension in the affected breast(s) that is not alleviated after breastfeeding
  • The development of abscesses (accumulations of pus) in the breast

Puerperal mastitis is often regarded as a bacterial infection of breast tissue, caused by exposure of these bacteria (most often Staphylococcus aureus and some Streptococci) on the skin of the mother or the mouth of the breastfeeding infant. However, some researchers believe that the association between bacteria and mastitis is less than robust.

A descriptive study compared breast milk samples of mothers with mastitis and control women. This study found that the counts of potentially pathogenic bacteria (Staphylococcus aureus and Group B streptococci) in the breast milk of women with mastitis were significantly higher. These bacterial counts were significantly correlated with the probability of mastitis symptoms. However, they were not correlated to individual symptoms or to symptom severity, although group B Streptococci counts were significantly associated with the number of visits to a health centre.

Non-puerperal Mastitis

Most cases of non-puerperal mastitis are periductal mastitis, or the inflammation of tissues around the duct of the breast(s) affected. Other forms of this condition may include:

  • Breast tissue inflammation related to bacterial infections
  • Breast tissue inflammation related to non-bacterial infections
  • Inflammation of the nipple
  • Infections in deep tissue (i.e. deep within the breast such as milk ducts, including plasma cell mastitis
  • Inflammation of breast skin

Essentially, any infection of tissues in or around the breast in the absence of lactation can be categorised as non-puerperal mastitis. The symptoms of non-puerperal mastitis may include:

  • Breast abscesses
  • Calcifications in breast tissue
  • Dilation of the ducts located behind the areola
  • Thickening of the skin around the breast

Unfortunately, these symptoms may be associated with inflammatory forms of breast cancer, such as carcinoma. Therefore, mastitis may often be misdiagnosed as a malignant condition. Conversely, in situ ductal carcinoma may mimic mastitis in some isolated cases. Some women with mastitis may also exhibit additional symptoms related to inflammation, such as:

  • Redness and/or tenderness in breast tissue
  • Skin redness
  • Feelings of fatigue and illness, as if experiencing the 'flu'

There are some other, often rarer, forms of mastitis, including:

  • Bilateral eosinophilic mastitis
  • Idiopathic (unilateral or bilateral) granulomatous mastitis
  • Mastitis as a result of infection with tuberculosis

Rare forms of mastitis may result in lesions that may also be misdiagnosed as breast cancer. These are composed of large populations of immune system cells involved in the production of inflammatory molecules. Some researchers conclude that granulomatous mastitis may have an autoimmune component. However, they may achieve full remission in response to appropriate treatment (e.g. medication).

Risk factors

Puerperal mastitis is thought to be associated with a number of risk factors. These include:

  • Incomplete expression of milk when lactating, leaving milk in the breast after feeding (also known as 'milk stasis')
  • Insufficient placement in relation to, or attachment to, the breast by the infant when feeding
  • Reduced feeding of (or by) the infant

Therefore, complete milk removal from the breast through expression is recommended when managing puerperal mastitis. Further management strategies are outlined below.

Management principles

Many forms of mastitis are typically treated with corticosteroids. This is a standard drug therapy that may significantly reduce inflammation. Other drugs used in the treatment of some forms of mastitis include methotrexate. Corticosteroids may be a second line of treatment if an initial line fails to eradicate the condition completely. However, relapse may occur in response to reductions in corticosteroid doses.

Severe lesions resulting from mastitis may require surgical removal. Surgery for mastitis may also be recommended in cases for which the symptoms have resulted in cosmetic detriments.  A longitudinal follow-up study including 31 patients with granulomatous mastitis assessed treatment options and the probability of relapse. The rates of relapse associated with steroid therapy and surgery were reported as similar (8.3%).

Treatment for abscesses may include drainage methods such as needle aspiration or open drainage.

The Role of Antibiotics in Mastitis Treatment

Antibiotics are often prescribed in cases of puerperal mastitis. These may be recommended on the basis of symptoms presented, tests for bacteria or the development of breast abscesses. Antibiotics typically recommended for this condition may include those of systemic antibiotics classes, such as:

  • Cephalosporins such as cephalexin
  • Lincosamides such as clindamycin
  • Penicillin derivates, such as amoxicillin or dicloxacillin

One study documented 192 women with this condition, 15% of whom were prescribed antibiotics based on either symptoms or bacterial culture results. However, there were no significant differences between the bacterial counts in their breast milk and those of patients who did not take antibiotics.

Another review found a trial that randomised 25 patients to treatment with cephadrine (n=12) or amoxicillin (n=13). This resulted in no significant difference between these groups in terms of preventing abscess formation or symptom resolution. This study found that two patients in the amoxicillin group experienced treatment failure, and one other experienced recurrent mastitis. Treatment with cephadrine resulted in recurrence for two patients.

Another study indicated that the combination of complete milk expression with antibiotic therapy was more effective than antibiotic therapy alone.

Corticosteroids may not be an appropriate treatment in cases of granulomatous mastitis in which infection is a factor. This is due to the increased risk of immune suppression associated with steroid therapy. On the other hand, the role of antibiotics in these cases is not straightforward. Some researchers assert that these micro-organisms are a factor in recurrent cases only.

Other strategies in mastitis treatment may include conventional pain treatments, increased rest and ensuring adequate hydration.

A study recruited 63 women with mild to moderate puerperal mastitis, and randomised them to a regimen of the application of a topical formulation containing the traditional anti-inflammatory curcumin every eight hours for three days, or conventional moisturiser as a placebo. The symptoms in the curcumin group were significantly reduced compared to those in the placebo group.

The Safety of Mastitis Treatment while Breastfeeding

The advisability of pain medication intake while breastfeeding varies from drug to drug, and is outlined in information found in pharmaceutical packaging. Some laboratory studies have shown that the concentrations of the antibiotics as above that transfer into maternal milk are not sufficient to cause severe adverse reactions in infants. A similar study of the cephalosporin cephalexin found that, while the dose in maternal milk was not sufficient to cause systemic effects in infants, it may have been associated with the incidence of diarrhoea observed in an infant subject.

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