Mastitis

Lisa Rahangdale, MD RID Seminar October 26, 2004

Mastitis
An acute inflammation of the interlobular connective tissue within the mammary gland

Outline
Epidemiology Presentation Predisposing factors Microbiology Treatment Complications Effect on breast milk

Epidemiology
Incidence 2-33%
ACOG reports 1-2% in U.S. Most common worldwide <10%

Most common 2nd-3rd week postpartum

74-95% in first 12 weeks Can occur anytime in lactation

WHO 2000

Presentation
Systemic illness: Chills, myalgias Fever of 38.5 Tender, hot, swollen wedge-shaped erythematous area of breast Usually one breast

Differential Diagnosis
Fullness: bilateral, hot, heavy, hard, no redness Engorgement: bilateral, tender, +/- fever, minimal diffuse erythema Blocked Duct: painful lump with overlying erythema, no fever, feel well, particulate matter in milk

Differential Diagnosis
Galactocele: smooth rounded swelling (cyst) Abscess: tender hard breast mass, +/fluctuance, skin erythema, induration, +/fever Inflammatory Breast Carcinoma: unilateral, diffuse and recurrent, erythema, induration

Causes and Predispsing factors

Causes
Milk Stasis
Stagnant milk increases pressure in breast leading to leakage in surrounding breast tissue Milk, itself, causes an inflammatory response

+/- Infection
Milk provides medium for bacterial growth

Causes
Study of 213 3 groups , 339 breasts

Milk stasis (bacteria<10^3, leuk<10^6) Noninfectious inflammation (bacteria <10^3, leuk >10^6) Infectious (bacteria >10^3, leuk>10^6)

Randomized treatment
No intervention Systematic emptying of breast Infectious group with 3rd intervention: antibiotics (PCN, Amp, Erythro) and systematic emptying
Thomsen 1984

Treatment Milk Stasis

No treatment Emptying

N 63 63 24 24 55 55 55

Sx duration (mean) 2.3 d 2.1 d 7.9 d 3.2 d 6.7 d 4.2 d 2.1 d

Thomsen 1984

p value

Noninfectious
No treatment Emptying

p<.001

Infectious
No treatment Emptying Abx +Emptying

p<.001 p<.001

Causes
Poor results
Milk stasis (10) 3 recurrences, 7 impaired lactation Noninfectious (20) 13 recurrences Infectious (76 only 2 in Abx group) 6 abscesses, 21 recurrences

Could not clinically tell difference between the groups without lab data. Conclusion: Treat with antibiotics
Thomsen 1984

Predisposing factors
Improper nursing technique
Timing of feeds Poor attachment

Oversupply of milk
Overabundant milk supply Lactating for multiples Rapid weaning Blocked nipple pore or duct

Pressure on Breast
Tight Bra Car seatbelt (yes, this is actually listed) Prone sleeping position
WHO 2000, Academy of Breastfeeding Medicine 2004

Predisposing factors
Damaged nipple (nipple fissure) Primiparity Previous history of mastitis Maternal or neonatal illness Maternal stress Work outside the home Trauma Genetic

WHO 2000, Michie 2003, Barbosa-Cesnik 2003, Academy of Breastfeeding Medicine, 2004

Predisposing factors
U.S. cohort of 946 Breastfeeding Telephone interviews 9.5% mastitis (64% diagnosed via telephone) Average symptoms for 4.9 days 88% prescribed medications
86% antibiotics (46% cephelexin) 17% analgesics

No cultures performed
Foxman 2002

Predisposing factors
H/O mastitis with previous child (OR 4.0, 95% CI 2.94, 6.11) Cracks and nipple sores in same week as mastitis (OR 3.4, 95% CI 2.04, 5.51) Antifungal nipple cream in 3 wk interval of mastitis (OR 3.3, 95% CI 1.92, 5.62) Manual breast pump (for with no prior history) (OR 3.3, 95% CI 1.92, 5.62) Feeding <10 times per day in same week
(for 7-9 times OR 0.6, 95% CI 0.41, 1.01) For 6 tmes, OR 0.4, 95% CI 0.19, 0.82)
Foxman 2002

Foxman 2002

Foxman 2002

Microbiology

Microbiology
Detection of pathogens difficult
Usually nasal/skin flora Difficult to avoid contamination

Milk culture
Encouraged in hospital acquired, recurrent mastitis, or no response in 2 days

WHO 2000

Microbiology
Staph Aureus Coag neg staph Also, Group A and B hemolytic Strep, E Coli, H. flu MRSA Fungal infections TB where endemic 1% of cases

MRSA in SF

Charlebois 2004

MRSA in SF
SFGH
Community Acquired: 70% Hospital Acquired: 50%

Moffitt
Community Acquired: 49% Hospital Acquired: 37%

VA 45%

MRSA
Risk factors for Community Acquired in SF
Homelessness (p=.015) Injection drugs (p=.02)

Difference in Strains
Hospital: SCCmec Type 2
More resistant May include Gent, Eryth, Quinolones, TMP/SMX, Clinda

Community: SCCmec Type 4

Susceptible to most ABX other than lactams

Carriage can be months to years

Charlebois 2004

Postpartum MRSA
Case reports Initially reported in Midwest NYC case-control study
8 cases (4 mastitis All CA-MRSA 3 breast abscesses)

Resistant to lactams Susceptible to Clinda, Flouroquinolones, TMPSMX, Gent, Rifampin, Tetracycline

No transmission route identified Associated with GBBS (p=.03)

Saiman 2003

Fungal infections
Based on case reports that anti-fungal cream improves sx Case reports of cyptococcal infection Most common: Candida Albicans
Genital tract Newborn oral colonization

May lead to nipple fissure Thought to be associated with deep, shooting pains and nipple discomfort Most commonly treated with fluconozole to , oral nystatin to infant

Fungal infections:
Is Candida associated with shooting breast pain?
Case series on deep breast pain
Isolated Candida in 5/20 (20%) patients Candida twice as often in superficial pain than bacteria Bacteria more often found in deep pain

Case-control study, Australia

61 nipple pain, 64 w/out nipple pain, 31 non-lactating More Candida in pain(19%) than control (3%), p<.01 Also, S. Aureus assoc w/ pain (p<.001) and fissures (p<.001) No Candida/S Aureus in non-lactating group

Brazilian study showed 32% colonization in milk of Asx

Amir 1996, Thomassen 1998, Carmichael 2001

Treatment

Treatment
Supportive Therapy
Rest, fluids, pain medication, anti-inflammatory agents, encouragement

Continue breast feeding Antibiotics that cover Staph and Strep

Culture results Severe symptoms Nipple fissure No improved sx after 12-24 hours of milk removal

86% of women in the U.S. get treated with Abx

WHO 2000, Foxman 2002

Treatment (ACOG)
Dicloxicillin 500 mg qid Erythromycin if PCN allergic If resistant to treatment penicillinaseproducing staph, then vancomycin or cefotetan until 2 days after infection subsides Minimum treatment 10-14 days

Treatment (Alternative)
Therapeutic U/S Accupunture Bella donna, Phytolacca, Chamomilla, sulphur, Bellis perenis Cabbage leaves Avoid drinks like coffee with methylxanthines, decreasing fat intake

Complications
(Other bad things related to mastitis)

Abscess
Most common in first 6 weeks 5-11% of mastitis cases Affect future lactation in 10% of affected Treatment: I & D, U/S guided needle drainage
Cohort of 19 with abscess: 18/19 successfully tx with U/S-guided needle drainage Cohort of 30 (33 abscesses): Tx with needle drg (no U/S), cure rate 82%, success assoc with smaller volume of pus (4 ml vs 21.5 ml, p=.002) and presented earlier (5 vs 8.5 days, p=/006)
Karstrup 1993, WHO 2000, Schwartz 2001

Abscess
Prospective cohort128 BF
102 mastitis (80%) 26 abscess (20%)

with infection

No differences b/t groups by age, parity, localization of infection, cracked nipples, + milk cultures, mean lactation time Duration of symptoms: only independent variable favoring abscess development
Dener 2003

Other Complications
Distortion of breast Chronic inflammation

Michie 2003, WHO 2000

Granulomatous Mastitis
Noncaseating granulomas in a lobular distribution Differential Diagnosis
TB mastitis Foreign body Fat necrosis Autoimmune: sarcoid, erythema nodusum, polyarthritis

Presentation
Unilateral Breast lump No infection identified at presentation
Heer 2003, Goldberg 2000

Granulomatous Mastitis
Can mimic Breast Ca on clinical, radiological, and cytological exams Diagnosis: Histology Treatment:
Antibiotics not helpful Corticosteroids Excision biopsy

Limited literature, but no clear association with breast feeding, OCPs

Heer 2003, Goldberg 2000

Subclinical Mastitis
No symptoms, usually unilateral Reduction in milk output Diagnosis: Increased milk sodium Causes
Milk stasis, poor nutrition, +/- bacteria

Public Health implication

Poor infant growth Increased risk of HIV transmission

Natural Hx and clinical implication unclear

Michie 2003, Filteau 2003

Effect on Milk

Immune Factors
IgA is predominant in milk Increased immune factors from both plasma and local epithelial cells No adverse events documented in peds
Poor growth documented likely related to poor milk production Contradictory studies showing benefit or harm

Interest in pediatric vaccine development

Michie 2003, Filteau 2003

Increased HIV transmission risk

Milk VL increases 10-20 fold Alternating breast/bottle increased risk Role of free virus vs cell bound virus unclear If must breast feed, then pump on affected breast (pasteurize) and feed on unaffected Subclinical mastitis: Problem -Lab dxs only
Michie 2003, Filteau 2003

Is there anything else?

Nipple piercing and mastitis

Review of 10 case reports on Med-line 7 female, 3 male 5 right breast, 4 left, 1 both Interval from piercing to treatment: 20.8 wks (2-52) Symptoms: 1 week to several months Complications: endocarditis, heart valve operation, prosthesis infection, metal foreign body in breast tissue, reoperation for recurrent infection, psychologic stress secondary to Breast CA dxs Conclusion:
Risk of nipple piercing under-documented and may be 10-20% Healing can take 6-12 months
Jacobs 2003

Take Home
Mastitis can decrease motivation to breast feed Remember Milk cultures if not getting better OK to Breastfeed (except HIV+)