Supportive and lactation management
› Symptom control and breast care
› Analgesia
› Ibuprofen 400 mg PO every 6 to 8 hours as needed
› Acetaminophen 650 mg PO every 6 hours as needed
› Hydration
› Oral fluids
› IV fluids if dehydration or sepsis physiology
› Local measures
› Cold packs for pain and swelling
› Warmth briefly before feeding if improves milk flow
› Milk removal strategy
› Continue breastfeeding if tolerated
› Infant safe with maternal antibiotics in typical regimens
› Improved drainage reduces stasis
› Pumping if infant cannot latch
› Gentle expression
› Avoid overpumping beyond infant demand
› Latch optimization
› Lactation consultant referral
› Address nipple trauma drivers
› Breast manipulation cautions
› Avoid aggressive deep massage
› Avoid excessive “emptying” goals when oversupply suspected
› Avoid traumatic pumping suction settings
Antibiotics for bacterial mastitis
› Indications
› Persistent systemic symptoms beyond 24 hours
› Moderate to severe local findings
› Cellulitis pattern
› No improvement after supportive care window
› First-line oral regimens for MSSA coverage
› Dicloxacillin 500 mg PO 4 times daily
› Duration 10 to 14 days
› Cephalexin 500 mg PO 4 times daily
› Duration 10 to 14 days
› Flucloxacillin 500 mg to 1 g PO 4 times daily
› Duration 10 to 14 days
› MRSA risk or beta-lactam allergy regimens
› Clindamycin 300 mg PO 4 times daily
› Duration 10 to 14 days
› C difficile risk counseling
› Trimethoprim-sulfamethoxazole 160 mg/800 mg PO twice daily
› Duration 10 to 14 days
› Avoid if infant premature or neonatal hyperbilirubinemia risk
› Treatment adjustment
› If no improvement after 48 hours
› Milk culture
› Ultrasound for abscess
› Antibiotic change based on susceptibilities
› Evidence framing
› Early supportive care window before antibiotics for mild cases
› Antibiotics when bacterial infection likely or systemic illness present
› Drainage strategy
› Ultrasound-guided aspiration
› Preferred initial approach when feasible
› Repeat aspiration for recurrence
› Catheter drainage
› Large collections
› Multiloculated collections
› Surgical incision and drainage
› Failure of percutaneous drainage
› Skin necrosis
› Complex loculations not amenable to aspiration
› Antibiotics with abscess
› MRSA-active coverage if risk or local prevalence high
› Tailor to aspirate culture results
› Breastfeeding considerations
› Continued breastfeeding or milk expression from affected breast when tolerated
› Avoid abrupt weaning during acute infection when possible
IV antibiotics and inpatient regimens
› Indications
› Sepsis physiology
› Inability to tolerate oral therapy
› Rapid progression
› Significant comorbidity or immunocompromise
› Empiric IV options
› Vancomycin IV dosing per weight and renal function
› MRSA coverage
› Therapeutic drug monitoring pathway
› Beta-lactam IV option for MSSA based on local protocols
› Transition to oral within 24 to 48 hours if improving
› Transition criteria
› Defervescence
› Downtrending pain and erythema
› Oral intake adequate
› Reliable follow-up
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