MastitisMastitis

Lisa Rahangdale, MDLisa Rahangdale, MD

RID SeminarRID Seminar

October 26, 2004October 26, 2004

MastitisMastitis An acute inflammation of the An acute inflammation of the interlobular connective tissue interlobular connective tissue

within the mammary glandwithin the mammary gland

OutlineOutline

• Epidemiology

• Presentation

• Predisposing factors

• Microbiology

• Treatment

• Complications

• Effect on breast milk

EpidemiologyEpidemiology

• 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

PresentationPresentation

• Systemic illness: Chills, myalgias

• Fever of ≥ 38.5

• Tender, hot, swollen wedge-shaped erythematous area of breast

• Usually one breast

Differential DiagnosisDifferential 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 DiagnosisDifferential 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 Causes and Predispsing factorsPredispsing factors

CausesCauses

• 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

CausesCauses

• Study of 213 ♀, 339 breasts• 3 groups

– 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 N Sx duration (mean) p value

Milk Stasis No treatment 63 2.3 d Emptying 63 2.1 d

Noninfectious No treatment 24 7.9 d Emptying 24 3.2 d p<.001

Infectious No treatment 55 6.7 d Emptying 55 4.2 d p<.001 Abx +Emptying

55 2.1 d p<.001

Thomsen 1984

CausesCauses

• “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 factorsPredisposing 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 factorsPredisposing 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 factorsPredisposing 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 2002Foxman 2002

Predisposing factorsPredisposing 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 2002Foxman 2002

Foxman 2002Foxman 2002

Foxman 2002Foxman 2002

MicrobiologyMicrobiology

MicrobiologyMicrobiology

• 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

MicrobiologyMicrobiology

• Staph Aureus

• Coag neg staph

• Also, Group A and B βhemolytic Strep, E Coli, H. flu

• MRSA

• Fungal infections

• TB where endemic – 1% of cases

MRSA in SFMRSA in SF

Charlebois 2004

MRSA in SFMRSA in SF

• SFGH– Community Acquired: 70%– Hospital Acquired: 50%

• Moffitt– Community Acquired: 49%– Hospital Acquired: 37%

• VA 45%

MRSAMRSA

• 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 β lactams

• Carriage can be months to years

Charlebois 2004

Postpartum MRSA Postpartum MRSA

• Case reports – Initially reported in Midwest

• NYC case-control study– 8 cases (4 mastitis 3 breast abscesses)– All CA-MRSA

• Resistant to β lactams• Susceptible to Clinda, Flouroquinolones, TMP-

SMX, Gent, Rifampin, Tetracycline

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

Saiman 2003

Fungal infectionsFungal 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:Fungal infections:Is Candida associated with shooting breast pain?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

TreatmentTreatment

TreatmentTreatment

• 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

TreatmentTreatment(ACOG)(ACOG)

• Dicloxicillin 500 mg qid

• Erythromycin if PCN allergic

• If resistant to treatment penicillinase-producing staph, then vancomycin or cefotetan until 2 days after infection subsides

• Minimum treatment 10-14 days

TreatmentTreatment(Alternative)(Alternative)

• Therapeutic U/S

• Accupunture

• Bella donna, Phytolacca, Chamomilla, sulphur, Bellis perenis

• Cabbage leaves

• Avoid drinks like coffee with methylxanthines, decreasing fat intake

ComplicationsComplications

(Other bad things related to (Other bad things related to mastitis)mastitis)

AbscessAbscess

• 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

AbscessAbscess

• Prospective cohort128 BF ♀ with infection– 102 mastitis (80%)– 26 abscess (20%)

• 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 ComplicationsOther Complications

• Distortion of breast • Chronic inflammation

Michie 2003, WHO 2000

Granulomatous MastitisGranulomatous 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 MastitisGranulomatous 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 MastitisSubclinical 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 MilkEffect on Milk

Immune FactorsImmune 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 riskIncreased 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?Is there anything else?

Nipple piercing and mastitisNipple 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 HomeTake Home

• Mastitis can decrease motivation to breast feed

• Remember Milk cultures if not getting better

• OK to Breastfeed (except HIV+)