Question:

A 36-year-old woman, gravida 2 para 2, comes to the office due to 2 days of right breast pain. She has also had fever, chills, muscle aches, and fatigue. The patient had a spontaneous vaginal delivery 6 weeks ago and has been breastfeeding her infant. Her husband has been feeding their baby pumped breast milk so that she can rest at night. The patient has no chronic medical conditions and takes a daily multivitamin. Her mother was diagnosed with metastatic breast cancer at age 55. Temperature is 38.8 C (101.8 F), blood pressure is 110/60 mm Hg, and pulse is 84/min. Physical examination shows a 5-cm area of erythema, induration, and tenderness at the upper outer quadrant of the right breast as well as right axillary lymphadenopathy. There is no fluctuance. The left breast has no abnormalities. Which of the following is the best next step in management of this patient?

Discontinue breastfeeding and prescribe antibiotic therapy

Order breast ultrasound and mammography

Order mammography and core needle biopsy

Perform incision and drainage and prescribe antibiotic therapy

Prescribe antibiotic therapy and continue breastfeeding

Recommend nonsteroidal anti-inflammatories and warm compresses only

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Lactational mastitis
Pathogenesis	Skin flora (eg, Staphylococcus aureus) enters ducts through nipple & multiplies in stagnant milk
Risk factors	History of mastitis Engorgement & inadequate milk drainage due to: Sudden increase in sleep duration Replacing nursing with formula or pumped breast milk Weaning Pressure on the duct (tight bra or clothing, prone sleeping) Cracked or clogged nipple pore Poor latch
Clinical presentation	Fever Firm, red, tender, swollen quadrant of unilateral breast ± Myalgia, chills, malaise
Treatment	Analgesia Frequent breastfeeding or pumping Antibiotics

This patient has lactational mastitis, a common infection in breastfeeding women due to inadequate milk duct drainage from pumping breast milk (instead of directly breastfeeding) or poor latch. Additional risk factors include infrequent feedings (as seen in this patient sleeping through the night), nipple excoriations, and rapid weaning from breastfeeding. Patients with lactational mastitis are diagnosed clinically and typically have flulike symptoms (eg, fever, myalgias), focal unilateral breast pain with surrounding erythema and induration, and axillary lymphadenopathy.

Lactational mastitis occurs when bacteria from the infant's nasopharynx or from the maternal skin are transmitted through the nipple and multiply in stagnant milk. The most common pathogen is Staphylococcus aureus, and treatment is empiric therapy against methicillin-sensitive S aureus with either dicloxacillin or cephalexin. Women with risk factors for methicillin-resistant S aureus (eg, recent antibiotic therapy, incarceration) are treated with clindamycin, trimethoprim-sulfamethoxazole, or vancomycin. In addition to antibiotics and analgesics (eg, ibuprofen), patients should continue breastfeeding every 2-3 hours because direct feeding from the bilateral breasts drains the milk ducts (Choice A).

(Choices B and D) Ultrasonography is indicated to assess for a breast abscess, which can present with fever, unilateral breast pain, and a fluctuant mass (not seen in this patient). Treatment of a breast abscess includes drainage and antibiotics.

(Choice C) Mammography and core needle biopsy are indicated in the evaluation of inflammatory breast cancer, which can present similarly to lactational mastitis (eg, breast pain, lymphadenopathy). However, patients with inflammatory breast cancer also typically have peau d'orange skin thickening and edema.

(Choice F) Nonsteroidal anti-inflammatory drugs and warm compresses are used in patients with breast engorgement. In contrast to this patient, those with engorgement have bilateral breast pain with generalized, rather than focal, involvement.

Educational objective:
Lactational mastitis presents with flulike symptoms, focal unilateral breast pain with surrounding erythema and induration, and axillary lymphadenopathy. Treatment includes antibiotic therapy against methicillin-sensitive Staphylococcus aureus (eg, dicloxacillin, cephalexin), analgesics, and continued breastfeeding.