Mastitis: Difference between revisions

 
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==Background==
==Background==
[[File:Breast anatomy normal scheme.png|thumb|Cross-section scheme of the mammary gland: 1) Chest wall 2) Pectoralis muscles 3) Lobules 4) Nipple 5) Areola 6) Lactiferous duct 7) Adipose tissue 8) Skin]]
*Inflammation of the breast tissue - can be infectious or non-infectious in etiology.<ref name="Amir">Amir LH. ABM Clinical Protocol #4: Mastitis, Revised March 2014. Breastfeeding Medicine. 2014;9(5):239-243. doi:10.1089/bfm.2014.9984.</ref>
*Inflammation of the breast tissue - can be infectious or non-infectious in etiology.<ref name="Amir">Amir LH. ABM Clinical Protocol #4: Mastitis, Revised March 2014. Breastfeeding Medicine. 2014;9(5):239-243. doi:10.1089/bfm.2014.9984.</ref>
**Continuum of disease - Plugged ducts → engorgement → non-infectious inflammation → infectious inflammation → abscess
**Continuum of disease - Plugged ducts → engorgement → non-infectious inflammation → infectious inflammation → abscess
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**Usually sub-areolar area due to chronic duct inflammation
**Usually sub-areolar area due to chronic duct inflammation
**40% recurrence rates even after [[I&D]]
**40% recurrence rates even after [[I&D]]
*[[Neonatal mastitis]] management is controversial, but typically requires IV and/or PO antibiotics with good staph coverage
*Neonatal mastitis management is controversial, but typically requires IV and/or PO antibiotics with good staph coverage


==Clinical Features==
==Clinical Features==
*Erythematous region on breast with well-localized area of tenderness
[[File:PMC3813587 rjt03901.png|thumb|Mastitis of right breast]]
[[File:Mastitis in breast.jpg|thumb|Mastitis localized to inferior portion of  left breast.]]
*[[rash|Erythematous region]] on breast with well-localized area of tenderness
*[[Fever]]/chills
*[[Fever]]/chills
*Flu-like symptoms
*[[Flu-like symptoms]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Postpartum emergencies DDX}}
{{Postpartum emergencies DDX}}


==Diagostic Evaluation==
==Diagnostic Evaluation==
*Ultrasound useful to identify abscess
*[[Ultrasound]] useful to identify [[abscess]]
*Routine labs not indicated unless<ref name="Amir" />:
*Routine labs not indicated unless<ref name="Amir" />:
**Treatment failure
**Treatment failure
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==Management==
==Management==
*If lactation mastitis, continue to breastfeed or pump, no need to dispose of breastmilk
*Warm compresses and massage, wearing supportive bra
===Antibiotics===
{{Mastitis antibiotics}}
{{Mastitis antibiotics}}


==Disposition==
===[[Abscess]]===
*Discharge if no concern for abscess
*Antibiotics as above
*Obtain breast ultrasound in ED if concerned for abscess
*If fluid collection is greater than 2cm, evacuation is recommended, with culture and sensitivity to guide antibiotic therapy
*If fluid collection is greater than 2cm, evacuation is recommended, with culture and sensitivity to guide antibiotic therapy
**If superficial <1cm from skin, I&D at bedside is recommended
**If superficial <1cm from skin, I&D at bedside is recommended
**If deep >1cm, consider percutaneous 18g needle aspiration. Percutaneous aspiration may also be appropriate for superficial abscess in a lactating patient to avoid milk duct fistula.  
**If deep >1cm, consider percutaneous 18g needle aspiration. Percutaneous aspiration may also be appropriate for superficial abscess in a lactating patient to avoid milk duct fistula.  
**if palpable mass persists after 14-21 days, ultrasound and needle biopsy should be performed of solid components by radiology department
==Disposition==
*Discharge, typically
*If signs of sepsis or WBC >15K or with left shift, consider IV antibiotics and admission
*If signs of sepsis or WBC >15K or with left shift, consider IV antibiotics and admission
*Consider Specialty Breast Services:
*Consider referral for outpatient Specialty Breast Services:
**if palpable mass persists after 14-21 days, ultrasound and needle biopsy should be performed of solid components by radiology department
**recurrent mastitis/abscess, or chronic granulomatous mastitis
**recurrent mastitis/abscess, or chronic granulomatous mastitis



Latest revision as of 18:34, 2 March 2020

Background

Cross-section scheme of the mammary gland: 1) Chest wall 2) Pectoralis muscles 3) Lobules 4) Nipple 5) Areola 6) Lactiferous duct 7) Adipose tissue 8) Skin
  • Inflammation of the breast tissue - can be infectious or non-infectious in etiology.[1]
    • Continuum of disease - Plugged ducts → engorgement → non-infectious inflammation → infectious inflammation → abscess
    • Infection occurs due to bacterial colonization secondary to areolar inflammation and glandular obstruction
  • Often occurs during the first few weeks to months postpartum, usually staph species with breast milk as culture medium
  • Post-menopausal usually due to E. coli, Group D strep, Staph, anaerobes[2][3]
    • Usually sub-areolar area due to chronic duct inflammation
    • 40% recurrence rates even after I&D
  • Neonatal mastitis management is controversial, but typically requires IV and/or PO antibiotics with good staph coverage

Clinical Features

Mastitis of right breast
Mastitis localized to inferior portion of left breast.

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Diagnostic Evaluation

  • Ultrasound useful to identify abscess
  • Routine labs not indicated unless[1]:
    • Treatment failure
    • Recurrent episodes
    • Hospital-acquired
    • Severe cases with systemic illness

Management

  • If lactation mastitis, continue to breastfeed or pump, no need to dispose of breastmilk
  • Warm compresses and massage, wearing supportive bra

Antibiotics

  • No need to routinely interrupt breastfeeding with puerperal mastitis.
  • For mild symptoms <24 hours, supportive care may be sufficient[1]
    • Effective milk removal (frequent breast feeding - use pumping to augment milk removal)
    • Analgesia (NSAIDs)

Treatment directed at S. aureus and Strep and E. coli

Abscess

  • Antibiotics as above
  • If fluid collection is greater than 2cm, evacuation is recommended, with culture and sensitivity to guide antibiotic therapy
    • If superficial <1cm from skin, I&D at bedside is recommended
    • If deep >1cm, consider percutaneous 18g needle aspiration. Percutaneous aspiration may also be appropriate for superficial abscess in a lactating patient to avoid milk duct fistula.
    • if palpable mass persists after 14-21 days, ultrasound and needle biopsy should be performed of solid components by radiology department

Disposition

  • Discharge, typically
  • If signs of sepsis or WBC >15K or with left shift, consider IV antibiotics and admission
  • Consider referral for outpatient Specialty Breast Services:
    • recurrent mastitis/abscess, or chronic granulomatous mastitis

References

  1. 1.0 1.1 1.2 Amir LH. ABM Clinical Protocol #4: Mastitis, Revised March 2014. Breastfeeding Medicine. 2014;9(5):239-243. doi:10.1089/bfm.2014.9984.
  2. Eryilmaz R et al. Management of lactational breast abscesses. Breast. Oct 2005;14(5):375-9.
  3. Dixon JM. Outpatient treatment of non-lactational breast abscesses. Br J Surg. Jan 1992;79(1):56-7.
  4. Levine BL. 2011 EMRA Antibiotic Guide. EMRA. Pg 78.